I'm having the same struggle -- with a twist. My DON expects me to complete accurate
assessments that reflect what the resident's condition really is BUT I don't have the
documentation to back it up. She wants me to know my patients, interview the staff
and read the chart. All of this I do --- I've even started coming in at 6 a.m. to
interview night staff. I can get days and evenings during the day because I certainly
don't leave any earlier. You know, as well as I that you can ask 5 different
caregivers and get 5 different answers. If my answers don't match the CNA or nurse
she interviews then she tries to make me feel like I haven't done my job. Lately, I
have been told to make a late entry reflecting the resident's actual condition so that
I can do the MDS to reflect what she thinks it should be. I have tried == to no avail
to explain what the look back period means and that when I look at the chart, I have
to look BACK from the ARD and that an entry after that is useless to me. I feel like
it is coming to the point that
I'm going to be asked directly to document falsely -- it's getting dangerously close
to that now. If assessments aren't done timely, I am expected to do them before doing
MDS. Lassst week, she told me I needed to "quit fighting her". This from a DON who
begged me to come to work for her. Before I took off work for 2 weeks for my
daughter's wedding )first time in 10 years I showed her the basics in case she needed
to help my replacement. Replacement didn't work out so she did them while I was gone.
When I came back, I had to correct every single one. Nevertheless, she is now an MDS
expert. I feel like I am being asked to do a job without any tools. If I am expected
to do my job, why aren't the nurses expected to do theirs..? I can't capture what
isn't documented. I've given one in=service to nurses on docuemntation for
information I need for Section G and Section H, our weakest links at present, and
charting improved. Am scheduled to do one for CNAs, whenever it is convenient but
can't pin down a date since it doesn't ap
pear to be a priority.
Guess this really doesn't answer your question. Guess I didn't realize how much this
was bothering me. Hope it is some comfort that someone else is having the same
problems.
>
> From: "Annette M. Corn" <[EMAIL PROTECTED]>
> Date: 2004/02/09 Mon AM 09:02:05 EST
> To: <[EMAIL PROTECTED]>
> Subject: FW: Medicaid charting 2nd Request
>
>
> -----Original Message-----
> From: Annette M. Corn
> Sent: Wednesday, February 04, 2004 6:18 PM
> To: 'Aanac Group ([EMAIL PROTECTED])'
> Subject: Medicaid charting
>
>
> After completing a the RUG III, Supporting Documentation and Case Mix
> Reimbursement class that deals with the system for Medicaid and RUG
> reimbursement, our facility has hit a brick wall in regards to the
> documentation. Specifically 7 day 14 day and 30 day(look back period)
> documentation that would support the MDS. We are trying without success
> to get the documentation we need. How has every one been dealing with
> this change? Are you using the same documentation as before? Has anyone
> come up with assessments just for Medicaid documentation and the
> specific look back periods? Are your staff complying? If not then what?
> One thing that stands out from the class was that best way to get
> accurate documentation from the staff for the 7 day look back for ADL's
> is to have only licensed staff document for those 7 days. What is
> everyone doing? If you have any documentation or a helpful solution I
> would love to hear it or see it. I realize this may be a time consuming
> question but please know your response is appreciated. I look for this
> information on the website daily and don't see anything which makes me
> think someone's got this figured out. Thanks for your undying support.
> [EMAIL PROTECTED]
>
>
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