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The problem with nurses’ notes - page 3 / 12





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November 2009

PPS Alert for Long-Term Care

Page 3

than one person knows how to fill out the MDS form. “There is high turnover for MDS coordinator positions,

which creates a problem because they are often the only person in the facility with a full understanding of how to fill out the MDS,” Foster says. “If the MDS coordina- tor leaves or falls sick, someone must be able to com- plete the MDS.”

Cheat sheets Even if all nurses are trained on the basics of the M D S , t h e f a s t - p a c e d n a t u r e o f t h e n u r s i n g h o m e m a y

limit their ability to apply this knowledge to documenta- tion. Documentation cheat sheets are becoming a popu- lar solution to this problem in nursing homes.

“In addition to having nurses chart from the care plan, you can put a piece of paper in front of the nurses’ notes section that outlines all the necessary things to document,” Foster says. For example, if a resident is re- ceiving skilled services for diabetes, Foster uses a diabetic cheat sheet that includes questions to consider when writing nurses’ notes, such as: Can the resident administer his or her own insulin? What is the resident’s oral medication? Does the resident’s diet affect his or her diabetes? Does the resident have any signs and symptoms of


Another technique is to develop a standard cheat sheet form that can be individualized for each resident, rather than having cheat sheets for specific conditions. Marshall developed a standard worksheet that not only outlines what nurses should document, but also reduces MDS compilation time for the MDS coordinator. (For a sam- ple of Marshall’s documentation cheat sheet, see “Care plan supportive documentation worksheet” on p. 4.)

Marshall’s documentation worksheet is meant to be filled out during the care plan meeting by the interdis- ciplinary team, who decides which issues are pertinent to the resident’s MDS. Each issue is assigned a number and recorded on the documentation worksheet, which is stored at the front of the nurses’ notes for that resident.

When a nurse goes to document for that resident, he or she will see this worksheet outlining issues that re- quire special attention. When the nurse writes his or her notes, he or she also writes the number that corre- sponds to the particular issue being documented from the worksheet. Now the MDS coordinator can look through the nurses’ notes for the numbers, rather than reading every sentence of the nurses’ notes for each shift in the time frame.

“For example, if a resident has pain that is unreported,

which is an MDS item, the interdisciplinary team should write ‘monitor pain’ on the documentation worksheet,” Marshall says. “If the corresponding number for this issue is 6, the nurses will write the number 6 in the date col- umn next to any documentation related to the resident’s pain. The MDS coordinator can then look through nurses’ notes, down the date column for the number 6, docu- ment the number of times pain was reported, and use this information for the MDS.”

In addition to documenting based on the care plan and MDS, Marshall’s worksheet can help nurses document

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    continued on p. 4

Free resources

During these difficult economic times, many SNFs are

cutting continuing education and professional develop- ment spending. HCPro understands that staying up to date on long-term care news and regulations is crucial for MDS coordinators and other long-term care professionals, espe-

cially as you prepare for the MDS 3.0. With that in mind, we offer the following free resources: MDSCentral (www.mdscentralonline.com). This free on- line resource provides you with information regarding the MDS, RUG-IV, and other long-term care news and regulations. Have a question? Visit MDSCentral today and ask our long-term care and MDS expert. MDS 3.0 Update. This biweekly e-mail newsletter keeps you informed on the most recent 3.0 develop- ments and features a regular Q&A with Regulatory Spe-

cialist Diane L. Brown. Visit www.hcmarketplace.com/ free/e-newsletters to sign up.

© 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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