This
is what I would do. I would interview staff that worked during the reference
period. CNA's, Activities, whoever you think. I would ask them the following -
Did
resident read the newspaper during period?? If no
Did
resident read large print material during period?? If no
Did
resident see objects in the environment during period?? If no
DId
resident follow you with eyes when you were moving about his environment.
Then I
would do a progress note stating interviewed such and such staff who worked with
resident during (dates of reference period) They stated blah blah blah
........... Thus will code vision on MDS as ...... Hope this makes sense.
Kristen
-----Original Message-----
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of MDSNancy
Sent: Wednesday, February 04, 2004 11:07 AM
To: [EMAIL PROTECTED]
Subject: RE: HELP! interviewing for informationOK, I understand that , yes, the nurses have missed the mark here. We will deal with that. What I need to know is, what do I do now? If the documentation isn't there? How do I answer that question on the MDS?
"Vogt, Kathy" <[EMAIL PROTECTED]> wrote:Was the assessment Medicare or OBRA? If medicare, you need to have the documentation of assessment during assessment window. If it is an OBRA, the MDS is a primary source document and would suffice. I would really look into why a visual assessment is not being done on admission.Kathy Vogt, RN-----Original Message-----
From: MDSNancy [mailto:[EMAIL PROTECTED]
Sent: Tuesday, February 03, 2004 6:13 PM
To: [EMAIL PROTECTED]
Subject: HELP! interviewing for informationI have seen here that it is acceptable to interview staff, resident's(?), etc, for information for the MDS. Here's my situation. None of the nursing staff documented on a resident's vision during the assessment period. Can I go to the resident myself, after the assessment window has closed, and find out for myself about her visual abilities? Then what do I document? I'll be dating it after the assessment window. My UMR has said that I cannot use anything outside of the assessment window. If I go back to the nursing staff and ask them to write an addendum note, I waste more time going back and forth to check if it's been done. What does everyone else do here, if you don't have the information you need to support the answers to the questions on the MDS???Thanks!
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