If you realize the information was in your time frame of the 5day, and it should of been on the 5day, then I would sent a correction to your state, (I also do the transmits qw/prn), then you would document it on your 14 day. DO NOT WAIT, for your 30 day. It will appear that your facility did not provide appropriate protective/ preventative skin meaures, mobility, nutrition, hydration, Vit C/MVI/Mag etc (you know the drill) to avoid this. If you recieved the info just after your 5 day window, and it is documented outside of your ARD for 5 day, then include it on your 14 day. You will have to do some heavy explaining in your raps. I personally try to go assess skin on admissions, what the floor nurses see and what I see usually is a mixed bag. It is easier to explain when noted and documented upon their admit to your facility, I will take pictures as well to CYA............
Claudia >From: [EMAIL PROTECTED] >Reply-To: [EMAIL PROTECTED] >To: [EMAIL PROTECTED] >Subject: necrotic heel >Date: Wed, 7 Jan 2004 06:18:12 EST > >We have a resident who has a necrotic heel but no documentation from MD/RN's >was found. This resident was admitted to acute hospital in October 2003 for >spinal stenosis had surgery, went home then went back to acute hospital in >December due to fall w/ fx right hip. I was able get a documentation from an RN >after my assessment window. I exported the 5D MDS assessment and not coded >section M and I'm ready to transmit the 14D assessment. My question is, should I >code section M for the necrotic heel even though there is no documentation on >my 5D and 14D assessment or should I wait for the 30D assessment to include >it on section M? >Thank you.
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