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- Oct 19, '06 by MDSnursingNo Way!!!
It cant be that easy. So your saying that its ok to not address whether they have symptoms of dehydration? Or house protocol to address fluid maintenence, such as routine water passes, etc? Amazing. I have been writing essays. Maybe need to start a new thread-have so many questions as to how everyone else is doing certain things-like are your resident being placed on alert status during your assessment period. What assessment tools do you use., etc. Job responsibilities. Will start one later. Thank you all for your help.
Struggling in Seattle.
- Oct 19, '06 by evalescoThe rap just indicates risk factors for dehydration, delirium, falls etc. But if you have a resident who is actuall showing s/s of dehydration that would be in your nrsg. notes, right? And your care plan should outline what your interventions would be for fall prevention, dehydration, etc.
I'm thinking if I hit that someone was dehydrated I would have labs nrsg. notes, MD intervention, etc. all which would be in the chart. To make the rap simple I would write...........
Resident was at risk for dehydration due to UTI and use of lasix BID, labs indicate a BUN of 65, MD was notified and orders are in the POS dated 10-19-06. Proceed to care plan.
Simple and it just tells you to find the information in the POS. Your care plan has the problem....at risk for dehydration r/t..............
then your goal---------------will be hydrated by evidence of blah, blah, blah,........
and then all your interventions...........
provide H2O, labs, MD etc etc.
Does that make sense?????
Maybe your state is different? But I was told by NASPAC and a state surveyor that the rap should be short and simple.
- Jun 26, '07 by JPR12You might want to contact a company we use at my home called Harmony-Healthcare. They came in and did an audit and found over $30k in one month of revenue due to different RUG levels and MDS coding and then taught our staff on skilled nursing and MDS
- Jul 14, '07 by ociannrsI ran across that situation. Discharge the day after being admitted, they were a late admit & therapy was not there to eval. They leave (hospital, home) & therapy misses the eval. You have to code yes for ordered therapies, but where therapy would enter projected minutes, they can't because they didn't eval. You have to enter zeros & you will get a non-rehab rug. Hopefully, you can get IV's, etc. to capture extensive services for a higher rug. They cannot be projected into a RM because they were not eval'd.
The facility that I work for has a regional MDS nurse that is available for questions & does certification courses for my companies MDS coordinators. When I had that situation just a week or so ago, that is what she advised me to do.