Don't forget to
interview your admissions person - was the resident able to read the
admission/HIPAA paperwork and sign them? Could they read names on staff name
tags? Our names are large print but additional information, i.e. job title,
hometown are regular size print - did they comment on that with anyone? You
can then interview the resident now and state in your note that a subsequent
interview with the resident on ___ date verified that they were able to read ___
print and expand on their visual acuity. Think outside the box. I had one
resident who could not participate in visual acuity testing d/t advanced
dementia, could not read because he never learned how to read but I observed him
picking up small (regular print sized!) cracker crumbs from his plate with his
finger without searching for them or swiping blindly at the plate. I coded him
as a 0 for vision and explained it in my note and the state loved it.
Deanna
-----Original Message-----
From: Kristen Tryba [mailto:[EMAIL PROTECTED]
Sent: Wednesday, February 04, 2004 9:42 AM
To: [EMAIL PROTECTED]
Subject: RE: HELP! interviewing for information
From: Kristen Tryba [mailto:[EMAIL PROTECTED]
Sent: Wednesday, February 04, 2004 9:42 AM
To: [EMAIL PROTECTED]
Subject: RE: HELP! interviewing for information
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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