Recon notes

  1. How do you all handle recon notes in your facility? Do you find yourself often having to code something completely different than all of the CNA documentation and how comfortable are you with the recon note if you are the only evidence in the medical record to justify coding, for example, an extensive assist when all of the CNAs are coding supervision & limited?

    We look at the resident's and review all documentation, including therapy notes. If we see somebody is an extensive assist, but the CNAs continue to document them incorrectly, despite being educated & inserviced several times, do we continue to recon the information with subsequent assessments?

    We have to recon on almost every assessment, but it does feel uncomfortable be the only documentation in the entire medical record to support our own MDS coding. We were basically told that since the ADL scores are low, and the CNAs "don't know crap", we need to disregard their charting and just recon what we say it is. Is this common in every facility?

    Any input would be appreciated.
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    About NurseMommyRN

    Joined: Nov '10; Posts: 10; Likes: 16
    from US
    Specialty: 9 year(s) of experience in MDS Coordinator