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The rules for ADL coding are that if it happened 3
TIMES you can code it. You don't need 3 days or 3 shifts but 3
times. Do the nurses notes describe any assist? Can you interview
staff and enter a note describing the assist that was given? Is there any
documentation from before admission that notes ADLs? If in your 7 day
window , you can count it. If all you can find is entered as total, and
there is no other documentation, I would code as total. Independent would
be entirely inaccurate.
----- Original Message -----
Sent: Wednesday, February 25, 2004 3:30
PM
Subject: Short stay resident
We had a resident admitted one evening and
transferred out next am to hospital where she died. Now I have only two codes
on my care tracker and I need at least 3 to code any one thing. What I have is
lots of totals. My inclination is to code it as 4s and 3s even if I only have
one or two although the tracker is averaging these as zeros-independent. She
was definitely not independent but I know the three time rule. Do I make an
exception in the unusual circumstances?
2nd question while I have your attention. I have
times when I have a resident that I think I may want to skill if therapy
cannot pick them up after a 3 day stay. One man had 5 stage 2 decubiti. I know
that could skill him. The problem is our wound policy states to change the
dressings every 3 days. I know we are monitoring dressings and circulation and
drainage and checking albumin levels and administering nutritional
supplements for wound healing and etc q day. Is this enough to skill even
though we are not changing the dressings? Thank you for your time.
Becky
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