Mds - page 2

I have been checking this site on a regular basis. I need some advise and assist with MDS. I have been a MDS nurse for the last year, recently the main coordinator resigned, now I am the only... Read More

  1. by   tex
    what if you don't keep an I & O record, we just have an ADL form the aides mark percentages of meal intake. Unless we have specific order's to do an I & O we don't do this. Do you have a form you use that is inclusive of meal intake. Our adl form has showers, bm's, sleep etc for the aides to do. It isn't that dependable, because the aides have a tendency to just mark either with a check for yes or place a zero. How would you fill out a rap for cognitive/communication and if a behavioral problem r/t verbal/yelling/combative resistive to care? and make it short, espically if tied into mood....thank you tex
  2. by   tex
    I forgot to ask, don't you have to put why they are not a candidate for a b/b program,,,,,,,,,,,explain. The mds cord prior to me, said you have to defend all of your statements in your rap process...tex
  3. by   jayray
    tex,
    yes, you would want to put why they are not candidate for b/b program. Resident is not candidate for b/b program r/t functional incontinence. (see cogniton/comm rap) That rap would state resident has dx of Alzheimers.

    We also had sheets the cena would fill out. Yes they will just fill in the boxes the same way the person before them filled it out. You can get around. When you put in the information on where you got the information for your section I would say... N.N dated 6/15/02 thru 9/15/02, Resident and staff interview, labs dated 6/16/02, ect. By asking staff specific questions you find out how they care for the resident and what they do for them. Always ask what they actually do not what can the resident do. Often they will say the resident dresses them self. But when you ask if they put on their own shoes and socks. It's " well no but she could" That will make her a 3-2 not a 0-0 for coding. That will make all the diference in your reimbursement money for that resident. At that time I will show the cena what she put on the adl record and help her fill it out for that day and of course everone else will fill it out the way she did. I would also stick a note on the adl sheet and let the other cena know what they need to mark. You may need an inservice on the proper way to fill out the forms for cena's.

    The MDI system is a program you need to purchase. Sorry but I just switched jobs and the place I work now does not use that system so I don't know where you would inquire.

    For mood/behavior you should be able to refer the rap bact to psych/social worker note that they have made in the chart that explains the behavior. Use them as a reference and put the burden of proving the behavior on them. If they are doing their job they should be assessing the resident. If they are on a psych rx put see psych note dated 2/15/02, see MAR, (If a nurse charted a behavoir say see n.n. dated 2/09/02)
  4. by   GeorgieGirl
    Hi Tex. MDI is a software system your company would have to purchase, I went to St. Louis to learn how to use it. We like it pretty well, but we did have to install a new server at my building because the database was so large. Each discipline at my facility enters their own section of the MDS in the computer. We nurses do most of the RAPs, but for Nutrition the RAP is the most recent dietary note, for Mood we use most recent SS note.

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