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PPS Alert for Long-Term Care

November 2009

Nurse documentation

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readily write deficiencies for not documenting something that was in the care plan.”

especially when the notes lack the necessary information,

says Marshall.

In addition to documenting based on what is included in the care plan, nurses’ notes should include informa- tion to support the skilled services provided to residents in a Part A stay and show why the individual needs to be a SNF resident.

Fortunately, there are techniques and systems facili-

ties can implement now to improve nurses’ documenta- tion and streamline the MDS compilation process, which will help SNFs with the MDS 2.0 and MDS 3.0.

“Sometimes, nurses don’t know why residents are on Medicare Part A or, for residents getting therapy, nurses may just write ‘At therapy.’ But this documentation does not tell us why the resident needs to be in a SNF. For all we know, the resident could live at home and go to out- patient therapy,” Foster says.

Reading through nurses’ notes to gather information for the MDS can be tedious, time-consuming, and frustrating,

MDS training for all

One way to improve nurse documentation and make the MDS process a little easier is to train all employees on the assessment system. Although not all SNF employees need to know every detail of the MDS, training nurses on

the basics of the assessment system will help them under- stand what they should be documenting.

“The majority of nursing schools do not teach the MDS, so many nurses have little or no knowledge of it

Editorial Advisory Board

PPS Alert for Long-Term Care

Group Publisher: Emily Sheahan Associate Editor: MacKenzie Kimball, mkimball@hcpro.com

when they go out to get their first job,” Foster says. “I think facilities should include MDS training in their ori- entation programs and make it mandatory for all nurses to learn the MDS.”

Sandra Fitzler Senior Director of Clinical Services American Health Care Association Washington, DC

Bonnie G. Foster, RN, BSN, MEd Long-Term Care Consultant Columbia, SC

Cindy Frakes Owner Winter Meadow Homes, Inc. Topeka, KS

Julia Hopp, MS, RN, CNAA, BC Vice President of Patient Accounting Paramount Health Care Company San Antonio, TX

Steven B. Littlehale, MS, GCNS-BC Executive Vice President, Healthcare Chief Clinical Officer PointRight, Inc. Lexington, MA

Mary C. Malone, JD Healthcare Attorne , Director Hancock, Daniel, Johnson & Nagle, PC Richmond, VA

Ronald A. Orth, RN, NHA, RAC-CT, CPC President Clinical Reimbursement Solutions, LLC Milwaukee, WI

Rita Roedel, MS, RN National Director of Clinical Reimbursement Extendicare Health Services, Inc. Milwaukee, WI

Rena R. Shephard, MHA, RN, RAC-MT, C-NE Founding Chair and Executive Editor American Association of Nurse Assessment Coordinators

President RRS Healthcare Consulting Services San Diego, CA

Holly F. Sox, RN, RAC-C MDS and Staff Development Coordinator NHC Lexington West Columbia, SC

Wayne van Halem, AHFI, CFE President The van Halem Group, LLC Atlanta, GA

In addition to teaching nurses about the basics of the system, SNFs should teach them how to document us- ing MDS language. For example, the RAI User’s Manual

includes tests you can conduct to help you code a resi- dent’s short-term memory at item B2 on the MDS 2.0. One test instructs the nurse to give the resident three words to remember (e.g., book, watch, and table), talk to the resident for five minutes, then ask the resident to repeat the three words. If the resident can repeat the words, he or she is coded as a 0 on the MDS. If the resi- dent cannot recall all three words, he or she is coded as a 1, meaning there is a memory problem.

“Instead of charting ‘alert but confused’ or some other vague note, nurses should complete this memory test

PPS Alert for Long-Term Care (ISSN: 1521-4990 [print]; 1937-7428 [online]) is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. Subscription rate: $239/year. • PPS Alert for Long-Term Care, P.O. Box 1168, Marblehead, MA 01945. • Copyright © 2009 HCPro, Inc. • All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978/750-8400. Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call 781/639-1872 or fax 781/639-2982. For renewal or subscription information, call customer service at 800/650-6787, fax 800/639-8511, or e-mail: customerservice@hcpro.com. • Visit our Web site at www. hcpro.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of PPSA. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

and chart ‘resident has a 1 in short-term memory.’ Then everybody would understand that the resident has a five-minute window,” Foster says.

Training nurses to document for the MDS is an ex- cellent start, but SNFs should also ensure that more

© 2009 HCPro, Inc.

For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.

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