MDS Alert

Published on Wed Aug 23, 2006 PDF

A multidisciplinary charting book can personalize care and augment the MDS.

Weeding through a long medical chart to gather information for the MDS or to personalize care, you sometimes can't see the trees for the forest.

Not only that but the chart doesn't include input from people who may interact with the resident, including housekeeping, maintenance and the resident's family members.

That's why Baldomero Lopez State Veterans' Nursing Home has implemented a multidisciplinary charting book that allows everyone to share their key observations and experiences with the resident. The nurses maintain the book at the nursing station.

The book includes a "face sheet" that has the resident's picture, his likes and dislikes, family members' and pets' names, etc., says Susan Poynter, activities director for the facility in Land O' Lakes, FL, who worked with the MDS coordinator to develop the new open documentation format.

Tapping the MDS: A lot of the information Poynter puts in the book comes from the MDS--for example, "the person's customary routines, likes and dislikes," she says. The book also includes the activities care plan. The book helps people working with the resident understand who he is and what the person likes to do and talk about, says Poynter. It also allows everyone to get credit for their quality interactions with residents, she adds. The staff can write "I spent 15 minutes talking to Mr. S about X, or I went with him to X group and he responded such and such."

Examples: One resident helped hold light bulbs for the maintenance person changing the bulbs and they had a chat about the resident's interests. "The maintenance person documented that the resident helped him," says Poynter. That type of documentation highlights a resident's participation in activities of interest that might otherwise escape the radar screen.

"Dietary can look at the book and find out what foods the person enjoys eating and then put those foods in the diet," says Poynter.

Enhance MDS Data Collection

The MDS team finds that the charting format provides information that might not be captured otherwise. "The book gives us a lot of useful information--especially for social services," explains Maureen Woods, RN, who is MDS coordinator for the nursing facility.

The book can reveal "how a new resident is adapting to the facility--and how the person sees his/her roles in the facility," Woods says. "It also helps social services and everyone on the team see if the person has depressive issues"--for example, if the resident isn't participating in the facility life, she adds.