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Our UMR team instructed me to keep a list of
when discovered, type of error, date corrected, section corrected etc for each
modification or inactivation. I keep this list in the front of my submission
book so that it is readily available for them.
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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