MDS Alert
Ensure The Clinical Record And Care Plan Back Up The MDS For Wounds
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If they don't, you could end up doing some serious backtracking with auditors.
Providing expert wound care and coding it correctly on the MDS aren't enough. You have to document the care consistently in residents' medical records.
A big problem: "The way that wound care is evolving in nursing homes, one nurse usually does the wound care and treatments. And that person may maintain those records separately," says Patricia Boyer, principal with Boyer and Associates in Brookfield, WI.
Proactive strategy: Facilities "need to get that information into the resident's clinical record, including how the wound appeared daily and when they did a dressing change," says Boyer.
Also: Record the wound interventions in the plan of care. Gail Robison, RN, RAC-C, with Boyer & Associates, finds that interventions are sometimes on the wound-care sheet but not on the care plan.
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