----- Original Message -----
Sent: Thursday, April 22, 2004 8:47
PM
Subject: Documentation
The following
questions probably sound strange to be asking but I am new to this and am in
need of the information.
Can anyone tell me what type of documentation
is required to support the MDS? And how often?
Even though the MDS is supposed to be a
source document you should still have some charting somewhere to back up the
info. You could use a flowsheet to capture info or just have the
nurses/cna's document in a narrative. For my PPS I use flowsheet for
each shift with area for narrative as well. As for the long term
the cna's have a flowsheet for the month and anything else in narrative
form.
What should I be asking the nurses to
chart?
Basically whatever is on the MDS. I know that sounds like
a lot but, the mood/behavior charting can just be by incident. As most
of the MDS. You need ability for adl's.
Is there anything
specific that I should be charting?
I
chart on the admission assessment, quarterly and PRN. That is for the
long term residents. Also if there is a discrepancy between charting and
MDS info you would want to note that. There is really nothing that
requires you to chart. You just need to make sure it is documented
somewhere by someone.
Is there specific documentation that should
be done during the observation period?
You should have info to
back up the answers that are on the MDS. As I said before this can be
done via flowsheets or narrative.
What type of documentation
should be done regarding the Care Plan meeting?
I write a narrative
note summarizing the meeting along with signatures of who attended. I
keep this in a file in my office. That is for the IDT
meeting. When I have care plan meetings with family/resident I write a
note in their chart summarizing that meeting.
Is there a
requirement to write a progress note when an MDS is opened or
closed?
No.
I
really appreciate any help that anyone can give me.
