Modifications

[Cheryl Walker]

I have a few questions for the group: 1. When your facility does modifications/inactivations to an assessment or tracker how do you document when the error was found and what the actual error was? In the policy that I have created for our facility, I suggested that a progress note be written and attached to the original assessment documenting when the error was found and what the error was along with the correction request form itself. I am getting "grief" over the extra documentation and that UMR and DOH may object to this. My feeling is this is telling them exactly where the error can be found and they don't have to search through the entire MDS to find it.What are others doing? 2. My billing person has told me that she won't need the billing logs that I have been doing for part A because the clinical software has a crosswalk to give her the RUG categories. She is also telling me that we don't need proof of MDS's being transmitted to the state database to bill. I am not aware that this has changed. I am a little nervous about this. I am still keeping the billing logs for my own records and documenting on them when the assessment has been transmitted. What are others thoughts? 3. Last but not least , a question has come up as to when coding on an MDS for example SOB- the resident is receiving O2, has a diagnosis of pneumonia and is receiving respiratory treatments we could check SOB in section J. The nurses notes do not mention that the resident is experiencing any SOB.I would not mark it because if not documented, not there. What does anyone else think? Thank-you for any input this group has on these issues.