Re: Clarification for documentation---What is correct????

[Holly Sox, RN, RAC-C]

I run into this situation quite frequently.  Typically, I find that the CNAs are more likely to know the resident's abilities with ADLs and mobility than the nurses. Also, most nurses without MDS training do not understand what "Totally Dependent" means for MDS purposes.   In order to code "4" for self performance, the resident must have required complete staff performance, every time the task was done for the entire 7 day lookback period. And for an alert resident with any function at all, it's pretty difficult to justify. For example, with dressing: does the resident put his arms through the sleeves when the shirt is being put on?  Does she hold onto the side rail when repositioning?  Does he bear weight or hold onto the wheelchair when transferring?  If so, then you cannot code total dependence. However, many staff nurses will write a note saying "totally dependent" or "requires max assist" for all adls.  I would address the status and documentation in my ADL RAP, stating that while nurses notes record total dependence, interviews with CNA staff and observation of the resident indicate that s/he is able to participate minimally with the tasks, and then describe what s/he is able to do. The ADL supplement which is in the RAI manual (after the ADL RAP guidelines) is an excellent tool for this purpose.   I have also written notes to clarify apparent discrepancies in documentation.   Page 1-20 of the RAI manual says, "Be aware of discrepancies and view the record information as preliminary only. Clarify and validate all such information during the assessment process. Be alert to information in the record that is not consistent with verbal information or physical assessment findings. Discuss discrepancies with other interdisciplinary team members. The extent to which the record can be relied upon for information will depend on the comprehensiveness of the record system. "   While the manual does not expressly state that the type of note you are describing is acceptable, I think it clearly indicates that the documentation in the record is not 100% reliable, and you will have to use clinical judgment at times.   There have been several instances where a discrepancy could have been significant enough to lead to a survey citation, but the RAP review and nursing note that I wrote clarified the situation sufficiently to satisfy surveyors.     Holly F. Sox, RN, RAC-C  Clinical Editor, Careplans.com www.careplans.com [EMAIL PROTECTED] ----- Original Message ----- From: [EMAIL PROTECTED] To: [EMAIL PROTECTED] Sent: Monday, January 12, 2004 10:12 PM Subject: Clarification for documentation---What is correct???? Rena or Nathan Please respond---And everyone else of course------   Here is the senario   Pt admitted  Jan  2nd  (Medicare)   5 day and OBRA admission assessment with an ARD of Jan 6th   CNA documentation  stated the pt is   3-2 bed mobility, dressing, toilting Nursing Documentation  states the pt is  4-2 for all of those things---   Which documentation do you use?????   And   is it appropriate for me to interview the staff  and write a clarification note   it would be dated  Jan 8th and I would reference the ARD of Jan 6th.  I can not find if this is the appropriate action to take anywhere in the RAI manual.  The coroprate MDS Nurse is telling me to write a note but she  does not have the documentation to prove that this practice is acceptable.   Thank You