New diagnosis

Talino · Jan 20, 2017

Do the SCSA.

If a significant change in status is identified in the process of completing any OBRA assessment except Admission and SCSAs, code and complete the assessment as a comprehensive SCSA instead

RAI bullet #2, p2-20

Melissamds17 · Jan 23, 2017

Thank you Talino

I have another pt with annual assessment ARD 01/16/17 and Per Weight Change Note dated 01/11/17

Pt loss (22%)X30day. Per Weight Change Note dated 01/20/17, Pt gained (5.8%)x1week. In this case where I have only one area of change I am hesitating to opened a significant assessment.

Talino · Jan 23, 2017

I can understand your hesitation - whether to just do the SCSA now rather than wait and be compelled to do the SCSA down the road.

That's a huge weight loss in 30 days. When the change is unclear whether it satifies the SCSA guideline, we have up to 14 days to determine if the criteria is met. To be safe, try to document the reason for the loss which "may be self-limiting" that will resolve with the current clinical intervention. 'looks like you are already seeing an improvement.

RAI, bullet 2, p2-25

If there is only one change, staff may still decide that the resident would benefit from a SCSA. It is important to remember that each resident's situation is unique and the IDT must make the decision as to whether or not the resident will benefit from a SCSA. Nursing homes must document a rationale, in the resident's medical record, forcompleting a SCSA that does not meet the criteria for completion.

You should be fine either way.

Melissamds17 · Jan 28, 2017

Thank you Talino for your support, I really appreciate it.