Our facility is trying to develop a system for adequate MDS documentation. We have tried posting diagnosis driven cheat sheets (document on at least 2 of these items/shift) posted on the chart and a check-off flowsheet with lines on the back for narrative notes. We have revised our CNA documentation flowsheets to reflect MDS language. Our 2 year trial of EMR CareTracker was a disaster and we have returned to paper.
It seems no matter how much inservicing, reminding, checking, reinforcing we do, our documentation is not there or inaccurate many times. Each time I do an MDS I get one set of information from the CNA sheets, another from the nurses notes and yet a different picture from staff/family interviews.
Has anyone successfully managed a way to obtain consistant and accurate documentation in the record?
Inadequate documentation
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