p2-8 The final decision re what constitutes sig change must be based upon judgement of clinical staff and guidelines ...
Sounds like the resident was care planned as comatose even though not designated as such- did you really need to alter her care plan any - sounds like clinical judgement would not support sig. change either.
From: [EMAIL PROTECTED] Reply-To: [EMAIL PROTECTED] To: [EMAIL PROTECTED] Subject: Need advice on what to do Date: Thu, 18 Mar 2004 07:45:28 EST
I have a situation that I'm not quite sure what to do . A resident was
admitted to our facility on 2/9/04 in what we considered a " vegetative state". The
MD did not document this despite the indication on the PRI that she was
comatose. He felt that she may come around because the family insists she responds
to them{ i highly doubt this}. A 5 day Initial mds and a 14 day mds were
completed which did not code her as comatose. A 30 day was done with the ARD of
3/8/04 that was then coded as comatose. After much discussion, I went to the
primary MD yesterday and spoke to him about this. She was even seen by a
Neurologist in Feb that only put as a Dx "severe OBS, CVA with Hemiplegia ,
non-responsive". The MD stated he would now write a note indicating the resident is in a
vegetative state. My question is what do I do now with the past assessments, do
I have to do a significant change since she technically is no different now,
do I have to do a sig correction to the old assessments, or do I go on from
here and code future assessments as comatose and write a note in the chart to
explain ?????? HELP... this one has me stumped.
Amanda Roth RN,C RAC-C
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