Re: Reasons for Sig. Changes

[Holly Sox, RN, RAC-C]

According to the manual, the sig change is not required unless there is a pattern of significant decline or improvement in 2 or more areas. I would not do the SC for any of the changes you mentioned in the absence of other changes.  However, like you said, it's better to try to explain why you did than why you didn't.  Whenever I identify any of the changes that you mentioned, I write a progress note explaining the change, and addressing the fact that other areas are stable. I ensure that the care plan is up to date. That way, if another change happens, then I have my documentation in order and proceed with the sig change at that time. If not, then I feel fairly safe that my care plan is appropriate and nothing is being missed.   HS Holly F. Sox, RN, RAC-C  Clinical Editor, Careplans.com www.careplans.com [EMAIL PROTECTED] ----- Original Message ----- From: [EMAIL PROTECTED] To: [EMAIL PROTECTED] Sent: Tuesday, March 02, 2004 10:52 PM Subject: Reasons for Sig. Changes Hello All,      I have a question to pose to the group.  It may sound silly, but I have always been under the impression that if you have a resident with a significant weight loss, you do a Sig. Change.  Also, for new stage 3 or 4 pressure area or  a new restraint.    I thought all of these should stand alone for a Sig. Change.  Here at work recently, some people have really been questioning and trying to get out of doing the changes.  I would rather have the Sig. Changes than try to explain why I didn't do one to the surveyors.  On our recent annual survey we had done a Sig. Change on a lady, then three months later she got a lap buddy restraint.  Surveyors cited us for not doing another change.  Sorta slipped through the cracks.   All info and opinions would be greatly appreciated. You all are a great resource.   Susan Gibbs, RN MDS Coordinator Presbyterian Homes of TN