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

[Nathan Hotmail]

I would decide which is correct, and write a note that says someting like, "Reviewed CNA documentation of <date> and Nursing Documentation of <date>. Spoke with CNA and nurse involved. Determined that resident is actually X-X for bed mobility, dressing, toileting because....".   It is never wrong to go back, review the situation, and clarify when two pieces of documentation are found to be inconsistent. Don't just say one is wrong, but explain why one is more correct.   If you just pick one and don't explain why, somebody (i.e. surveyors) can claim you were wrong. Don't leave the documentation in a contradictory state.   Nathan ----- Original Message ----- From: [EMAIL PROTECTED] To: [EMAIL PROTECTED] Sent: Monday, January 12, 2004 7:12 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