MDS Alert

Published on Thu Oct 26, 2006 PDF

This simple strategy can head off problems down the line.

As an MDS nurse, you have an opportunity to set the medical record straight -- literally.

"MDS nurses should write an MDS progress note with each assessment they complete and address any discrepancies they noted in the record," advises Roberta Reed, MSN, RN, clinical care manager at Legacy Health Services, which operates nursing homes in Ohio.
 
Beware: Without a note from the RAI staff explaining coding decisions in the case of discrepancies in the medical record, then all a reviewer of the MDS has to go by is what's in the medical record, cautions Julie Thurn-Favilla, RN, MSN, a consultant with LarsonAllen in Milwaukee.

Key example: Discrepancies sometimes occur between how nursing and therapy sees a resident perform his ADLs, says Reed. "The progress note gives the MDS nurse an opportunity to explain why she coded the MDS the way she did based on conflicting information."

Say the MDS nurse finds discrepancies between the ADL flow sheets and her interviews with CNAs, the resident and family members and resident assessment. In that case, "she needs to document in the medical record that the MDS is a better reflection of the patient's status" based on interviews and nursing assessment, advises Cindy Hart, LPN, CPA, CPC, a consultant in Jenkintown, PA.

Explain Your ARD Selection

"The progress note can also explain why the team chose the ARD it did -- especially if that's not obvious," says Reed. "The note might say we selected day 8 because the resident was receiving very high therapy." The reason for selecting the last available grace day in that situation is obvious, adds Reed. But in a different scenario, "it might not be obvious that you picked day 8 because on day 7, the staff noted that a resident has a Stage 3 ulcer that no one had correctly staged until then."