Re: Raps
In the "Location and Date of RAP Assessment Documentation" I would enter "See RAP Summary ____ (date)". In the RAP summary, I would then either WRITE a complete summary, or reference other parts of the chart in which the information is summarized or discussed. For certain RAPS, such as nutritional or feeding tubes, there is usually room to directly enter the date/info in the column--"Dietitian's monthly note 6-6-07".
The RAI Manual, on page 4-24, gives this one example of referencing particular dated notes:
Delirium: RAP Summary Example 2
Mr. S triggered for delirium. RAP was used as a guideline for assessment by team. (See nursing notes: 8/24/02, 8/28/02, MD note 8/25). Possible causal factors: UTI, Medication, Dehydration, Relocation have been identified and treatment plans are indicated. Refer to Delirium care plan.
There are other examples given for a RAP summary which reference a particular document, with no date. Here is one on page 4-15
PROBLEM: IMPAIRED PHYSICAL MOBILITY
Mrs. X has impaired mobility... We will continue current care plan of walking, titrating weights per protocol (see strength training progress form) and individual progress note.
The main purpose of the RAPs is to
- obtain an interdisciplinary overview of the trigger,
- decide if it is, or isn't a problem for this resident (based on current documentation or documentation of a thought process which "puts it all together"), and
- define the problem, and
- develop an interdisciplinary approach (with the resident) to this defined problem using evidence-based protocols/guidelines.
If your medical record documentation and care plan shows this "thinking", am not sure how you can be cited for completing a form "incorrectly", as even the RAI manual is not clear how this "form" should be completed.
Concentration and efforts spent to complete the "form" correctly is one reason professionals give to explain how RAPs impede effective interdisciplinary assessment and planning.
Good luck!
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