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I agree with Nathan on all 3 points.
Especially #3. It also ties in to the question posted earlier about
section K: whether to always code "Chewing Problem" if someone has a
mechanically altered diet.
These situations, to me, are documenting based on
assumptions. IE, the person got resp tx and O2, therefore I assume s/he must
have been SOB. S/he is receiving a mechanically altered diet, so I assume s/he
must have had a chewing problem.
Only problem is, we all know what happens when we
assume. The only time I use MDS as primary information (or the first place an
event is documented) is when it is an event that I witnessed or assessed, but
that no one else has documented. In these instances, I do code it on the
MDS, then write a progress note or RAP explaining it. For example, "No mood or
behavior problems noted on review of nursing notes or SW notes. However, on 2
occasions during the assesment period, resident was verbally abusive and very
negative in speaking to me when approached for assessment. When
interviewed, staff report that he is often "grouchy" upon awakening, and "cusses
them out" almost every day. SW notified for follow up, and MD consulted for
possible psych eval or medication adjustment."
HS
----- Original Message -----
Sent: Thursday, February 19, 2004 8:38
PM
Subject: Re: Modifications
1. I fully agree with your documentation. The
surveyors will have a complete list of all Modifications and Inactivation if
they so choose., Therefore, you might as well make it easy on them to
find what they are going to be looking for. There is no specific requirement
to document when you found the error, but since you must do the correction
within 14 days of finding it (p1-8 Provider Instructions for MDS Correction
Policy), there is an implied requirement.
2. Nothing has changed here. You still must
submit and have the assessment accepted before you can bill.
3. You could make an assumption that the resident
is SOB, but surveyors tend to frown on that action. This gets back to the MDS
as source documentation question. I never liked that idea of the MDS being the
only documentation. I would not check it without supporting docs even in a
case where it is probably a clinical no-brainer.
Nathan
----- Original Message -----
Sent: Thursday, February 19, 2004 4:43
PM
Subject: Modifications
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.
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