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Page 4

PPS Alert for Long-Term Care

November 2009

Nurse documentation

< continued from p. 3

skilled needs, short-term needs (e.g., documenting for

signs and symptoms of adverse reactions to an antibiotic or exacerbation of a fall), or additional information.

Documentation cheat sheets, whether they are for specific conditions or individualized for each resident, make the MDS coordinator’s job easier because they tell nurses what to document, close the loop between the MDS coordinator and floor nurses, and trim the time needed to fill out the MDS.

begin changing what they can now will be better prepared for the transition to the MDS 3.0.

Providing MDS training for all staff members and im- plementing a documentation cheat sheet method will not only save valuable time once the MDS 3.0 is imple- mented, but will also benefit SNFs under the current MDS 2.0 system.

“Regardless of how long it takes to fill out the MDS, it is always helpful to cut down on time where you can,

A win-win situation

Even if the MDS 3.0 is a quicker assessment process than the MDS 2.0, SNFs will undergo many time-consuming changes as the new system is implemented. Facilities that

as long as you are not sacrificing the quality of the work you put into it,” Marshall says. “If nurses are aware of the details of MDS and understand what to include in their notes, the whole process will be faster and easier now and in the future.”

Care plan supportive documentation worksheet

Date 3/16

Problem # 3

Approach Transfer from wheelchair to commode with standby assist; include any balance problems

Once per day

3/16

4

Resident dresses upper body with minimal assist

X

X

Documentation frequency

per

per

shift

week

Room number:

__2_1__2_A_________________

Date from: _3_/_1_6_/_0_9_______

Part A skilled need:

Physical therapy (PT) and occupational therapy (OT) _________________________________________________

Once

Once

Resident:

John Smith _____________________________

To:_4_/_1_/_0_9________

Comments PT and OT are training for this; watch for progress

OT is training this; watch for progress

3/16

2

3/16

9

3/16

6

3/16

5

3/16

8

Resident walks with walker when not in therapy Resident to consume 75% of meal, or provide house shake Resident to verbally state pain and location

Document incontinence outside of toileting schedule Document, if patient falls: time, date, and injuries

X

X

X X

X

PT is training this; watch for progress All three meals

Source: Carol Marshall, MA, long-term care consultant, Fort Worth, TX. Reprinted with permission.

© 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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