As with most things in healthcare, good documentation can save you. It would have been good practice to write a note with quarterly 1 stating that the ADL decline was due to short-term illness and that you would reassess in 2 weeks. Put a note on your calendar, and then in 2 weeks if the ADLs have improved, write another note documenting that the illness has resolved, no significant change is noted. With the second quarterly, compare the resident's status vs the status on the annual assessment. If there have not been 2 changes and the care plan is accurate , you have nothing else that you need to do. Since that documentation is probably not there, assess the resident's present status as compared to the status on the comprehensive assessment. If there are not 2 consistent changes you are fine, since your care plan is up-to-date. ----- Original Message ----- From: "Conley, Donna" <[EMAIL PROTECTED]> To: <[EMAIL PROTECTED]> Sent: Friday, March 12, 2004 9:03 AM Subject: Any Suggestions?
> We had a person who had comprehensive assessment done 9/03. Then had > Quarterly done 12/03. Had next Quarterly done late in month of 2/04. Here > is the problem....the 12/03 quarterly showed ADL decline due to pain in two > areas. . The 2/04 Quarterly shows ADL improvement in those areas due to pain > control. The 2/04 Quarterly also reflects foley cath discontinued and > changes in continence. The care plan reflects all this in an accurate > manner.I know the ADL decline was not permanent. However none of the > assessments was ever done as a Significant Change Assessment. Any comments > or suggestions on what we should or should not do? Just discovered this > today. Thanks. > /---------------------------------------------------------- > The Case Mix Discussion Group is a free service of the > American Association of Nurse Assessment Coordinators > "Committed to the Assessment Professional" > Be sure to visit the AANAC website. Accurate answers to your > questions posted to NAC News and FAQs. > For more info visit us at http://www.aanac.org > -----------------------------------------------------------/ /---------------------------------------------------------- The Case Mix Discussion Group is a free service of the American Association of Nurse Assessment Coordinators "Committed to the Assessment Professional" Be sure to visit the AANAC website. Accurate answers to your questions posted to NAC News and FAQs. For more info visit us at http://www.aanac.org -----------------------------------------------------------/
