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Save valuable time with strategies to improve nurse documentation

MDS coordinators are often expected to accomplish m a n y t a s k s i n a s h o r t p e r i o d , a n d a s f a c i l i t i e s f a c e t h e

challenges associated with MDS 3.0 implementation,

lack of time may become a more pressing problem. “CMS has said that the MDS 3.0 will not take any more time to complete than the MDS 2.0,” says Carol

Marshall, MA, a long-term care consultant in Fort Worth, TX. “Although this may prove to be true once facilities are comfortable using the new system, adapting to change is time-consuming.”

To successfully transition to the MDS 3.0, SNFs will have to develop new policies and procedures, train all staff members, and foster good interviewing and docu-

mentation skills among employees.

These tasks will require time and effort from SNF staff members and add to the MDS coordinator’s lengthy to-do list.

IN THIS ISSUE

p. 5

Coding Section B Coding Section B of the MDS 2.0 can be a challenge for many MDS coordinators, but it doesn’t have to be. We offer tips so you can code this section with ease.

p. 7

IV medications Help your facility get the documentation needed to code IV medications provided during a resident’s acute care stay.

p. 9

Culture change Many recent regulations and guidance include aspects of culture change. What does this mean for your SNF?

p. 10 MDS professor Think you’re an MDS expert? Test your knowledge with our quiz.

p. 11 PPS Q&A Columnist Wayne van Halem, AHFI, CFE, discusses what to do when an internal audit reveals billing errors.

November 2009 Vol. 12, No. 11

“It is not uncommon for an MDS coordinator to spend two or more hours completing an MDS, but it doesn’t have to be this way,” Marshall says.

MDS coordinators can save valuable time by tackling one of the most demanding aspects of the assessment system: nurses’ notes.

The problem with nurses’ notes

The MDS coordinator and members of the interdisci- plinary team use information from the resident’s chart to complete the MDS. The notes and docu- mentation provided by the floor nurs- es are important components of this “It is not uncommon for an MDS coordinator to spend two or more hours completing an MDS, but it doesn’t have to be this way.”

process and help de- —Carol Marshall, MA termine how certain

MDS items will be coded. However, if the nurses do not know what to document or how to properly do so to sup- port the MDS, their notes may be of no help to the inter-

disciplinary team.

“When nurses are unsure of what to write, they may just copy notes from a previous shift or record some- thing like ‘quiet day,’ which does not help the MDS team complete the assessment,” says Bonnie G. Foster, RN,

BSN, MEd, a long-term care consultant in Columbia, SC. “When I see this, I always ask the nurses, ‘Have you ever

had a quiet day in long-term care?’ ”

Nurses care for numerous residents every day, and it can be difficult to write notes that include all the neces- sary documentation for each resident, which is typically

outlined in the care plan.

“Most floor nurses document by incident, knowledge, or observation, rather than by what is included in the care plan,” Marshall says. “However, state surveyors will

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