One of
the things I learned at my NAC training course in Iowa this summer, and hope we
have correctly implemented at our facility, is the use of "worksheets" for for
"staff use only" such as pain records, B&B records, 7 Day observations, and
Nursing Assistant Rehab. and Behavior sheets, and Mental Status exams. When we
do the RAPs or MDS assessment we do a narrative summary which summarizes the
data in the "worksheets". On a RAP sheet we refer to the MDS summary as the
source of information for the RAP. We then have a policy that the worksheets are
kept for thirty days and then destroyed. Between scheduled assessments we do
basically the same for instance if we do a pain record, the RNAC summarizes in
Nurses's notes and then disposes of the worksheet after 30 days. Of course
before we had implemented this this Fall we had a surveyor find one incorrectly
coded pain response of a "10" on a pain record and they gave us an actual harm
deficiency for not treating the pain appropriately even though all other
evidence indicated the resident was experiencing minimal pain and not even on a
daily basis and the MDS Summary correctly summarized the data excluding the
aberrant "10". Of course one of the surveyor said she didn't know if she
liked our Policy of worksheets when they resurveyed and gave us a clean slate. I
hope we are interpreting this correctly and would love to hear from other
RNACs.
Mark
Abrahamson, RNAC, MA
Grand
Marais, MN
-----Original Message-----There were some SNF in my area that just did a check off system, and the citations killed them.
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]
Sent: Friday, January 16, 2004 9:42 AM
To: [EMAIL PROTECTED]
Subject: Re: RAP question
Just to clarify - "check-off systems" are fine for the assessment portion of working the RAPs. However, missing the second step of the process is what gets facilities in trouble. After going through the checklist and marking whatever applies to the resident, the clinician must analyze the results and draw conclusions regarding the true nature of the problem, risk factors and complications related to the problem, and factors for individualizing the care plan, etc.. That is what is required to be found in the chart somewhere/somehow, as stated at the top of Section V of the MDS.
Rena
Rena R. Shephard, MHA, RN, FACDONA, RAC-C
Chair, American Association of Nurse Assessment Coordinators
[EMAIL PROTECTED]
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