Re: Surveyor thinks I miscoded section E Originally Posted by KingDom
The surveyor replied "well, I'd be anxious, too--wouldn't anybody?"
And my answer to him/her,
"If the MDS was about you, I'd code it exactly the same way!" Albeit, I'll be a little discreet
- RAI p1-19, bullets 2-5, clearly specify "Communication with..."
- Same page, last paragraph --- "... Starting with the resident’s record, however, does not indicate that it is the most critical source of information, but only a convenient source."
So, whose convenience? In your case, that of the surveyor's!
Yours is but a minor hassle. Remember, the MDS is a legal document itself. You witnessed the event. The SW corroborated. By entering your signature in the MDS, you attested to the accuracy of the info you entered in that MDS.
And, if the PRN med for insomnia given on two occasions is not satisfactory to support the MDS coding, the facility may well be cited of dispensing medications without a need.
Most surveyors are not experts in the MDS as they purport to be. But they sure can raise havoc with their own interpretation or an uneducated opinion.
Nursing News