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

[Brenda Chance]

That is what nursing is all about.  That is why I suggested that she write the note clarifying what she is coding.  But, again, per the manual, the mds is a source document which means it stands alone without clarifying documentation.  It is BEST  to have that documentation to support it and this is accepted standards of practice in the medical field.  I always write a RNAC progress note so that it can be noted why I am coding what I am coding.  See pg. 1-23 of the manual and this will explain what I am talking about.    Brenda W. Chance, RN, RAC-C MDS Coordinator     CONFIDENTIALITY NOTICE: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. -----Original Message----- From: LINDA FUCHS [mailto:[EMAIL PROTECTED] Sent: Tuesday, January 13, 2004 9:46 AM To: [EMAIL PROTECTED] Subject: RE: Clarification for documentation---What is correct????   Since when do you not need documentation to support your MDS? I live in ND and if a family appeals my MDS I have to prove why I coded it the way I did. In our state if you can't show that you were doing something, then you didn't do it.  Linda >>> [EMAIL PROTECTED] 01/13/04 07:40AM >>> It is very appropriate to interview the staff, etc. and write a clarification note.  Remember the MDS is a source document which means it does not require documentation to support its coding, but, of course, this is what we strive for and what should happen.  I find this a lot in my facility.  Unfortunately, not all nurses and CNA’s understand the MDS coding, thus the discrepancy.  Code the MDS appropriately.   Brenda W. Chance, RN, RAC-C MDS Coordinator     CONFIDENTIALITY NOTICE: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] Sent: Monday, January 12, 2004 10:13 PM To: [EMAIL PROTECTED] 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 CONFIDENTIALITY STATEMENT: This message is intended for the sole use of the individual and entity to whom it is addressed, and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If you are not the intended addressee, nor authorized to receive for the intended addressee, you are hereby notified that you may not use, copy, disclose or distribute to anyone the message or any information contained in the message. If you have received this message in error, please immediately advise the sender by reply email and delete the message. Thank you.