MDS Alert
To Code Or Not To Code … ADL Assistance In The Hospital
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Question: Can nursing homes capture ADL care on the MDS if it was provided during the hospital lookback?
Ohio facility
Answer: The instructions for item G1, ADLs, do not specify that information should be collected "since admission only" and do not in any other way instruct the assessor to omit information captured in the lookback period that occurred prior to admission. Therefore, you should include activities-of-daily-living care provided in the hospital that is captured in the lookback period when making the coding decisions for G1.
The SNF medical record must contain enough information so that a surveyor or other auditor understands by reading the chart how you came to the coding decision documented on the MDS.
Source: Answer provided courtesy of Rena Shephard, RN, MHA, FACDONA, president, RRS Healthcare Consulting, San Diego, CA, and founding chair and executive editor of the American Association of Nurse Assessment Coordinators.
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