Published Feb 8, 2002
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SO THAT WHEN THE STATE SURVEYORS COME IN AND ASK QUESTIONS RE PSYCH MEDS,WEIGHT CHANGES I WILL HAVE A LITTLE SUMMARY WITH BACKGROUND INFO. TO PRESENT TO THEM. I WILL ALSO HAVE A AREA AT THE END OF IT THAT IF IT IS DEEMED NOT TO ATTEMPT REDUCTION OF MEDICATIONS I CAN DO A RISK/BENEFIT AND HAVE THE M.D SIGN IT ON ROUNDS.
What a surveyor would want to see is some of this information coming from the Pharmacy consults. They also look to see there is a Diagnosis warranting the use of psych meds. Many facilities have this printed on MARs by the drug. They also like to find this information in the progress notes section of the charts. I understand trying to make stuff easy for the surveyors to find in the charts... heaven knows we like things handed to us without having to dig through the chart. Sounds like you are writing a mini RAP after quarterlys. Why are you doing more work than you have to. The MDS/RAC Nurse position is already over worked and under appreciated.
catsrule, Amen, I think most other nurses in the facility don't really understand the role of the RNAC. Our MDS Coord isn't required to work the floor etc. Bless this facility. I left my last job because I was working 3-4 days out of 5 as a floor nurse. + being expected to keep up with PPS assess, medicare coverage issues, training of CNAs, all MDS scheduling, Restorative nurse program. I know this is not uncommon. They reassured me several times that this would end but in 2and 1/2 years it never did so I moved on. As soon as Adminstrators figure out that this is where the money is coming from, I think it will change. Hope so anyway.
I have been an MDS Coordinator at a 120-bed facility for 1 1/2 yrs. There is a Medicare Coordinator for the 20-bed Subacute Unit and then the rest of the 100 beds are mine (Medicaid, Private Pay). Our facility uses a corporate intranet and MDSs, RAPs, and HCFAs are all on computer. We are going to start using the care plan function but this was supposed to happen a year ago so I don't hold my breath. I do have quite a few canned care plans that I wrote up on my computer in Word and copy off. These have goals and interventions that can be checkmarked. The surveyors so far have not found anything wrong with them because I can tweak them to make them more individualized but I keep them vague enough not to hang us.
I do a Wellness Clinic with social services, therapies, activities, housekeeping, and dietary every Thursday. We split up and see the list of residents on the first day of the observation period and that way each discipline can chart as needed for documentation. We have a meeting after so we can all discuss what we found. Care plans meetings with families are done on the Wednesday prior to the Wednesday we actually write the care plans so we can address what they observe. The other days are spent gathering information and charting.
I like the idea of a quarterly summary as the monthly summaries are just not being done right and the ADL worksheets the aids fill out aren't being filled out or when they are, they have no idea what those numbers are (an 8/8 for eating, or 0's for people who require full assist). I think that might be a good thing for the Unit Managers to handle, I've got a full plate already.
I do like doing the MDSs but they sure get a person's head spinning after a few hours!
I am a LPN and have been doing MDS for over two years, I have used Achieve and Vista systems both have Care Plans, but I keep a book of my own of Care Plans, which I can individualize, I have taken Fl Health Assoc. Cert and Florida Risk management and am taking AANAC course now, there is something new everyday to learn, I work in a 240 bed facilty we have three co-ordinators. I have the same problem on documentation I have given lists, memos, red dots, any suggestions beleive me I know the nurses are busy but you have to have documentation.
I LIKE THE IDEA OF USING WORD TO CARE PLAN, TRUTHFULLY I NEVER THOUGHT OF DOING THAT. I WAS TYPING THEM ALL OUT BY HAND. THANKS
I USE THE SUMMARY AS A MINI RAP TO JUSTIFY MEDICATION REDUCTIONS WITH THE HISTORY SO I KNOW WHERE I AM IN REDUCTION. I ALSO USE IT TO TRIGGER ME TO CHECK BEHAVIORS AND SEE IF I NEED TO CHANGE THEM OR TO GET A RISK VS BENEFITS FROM THE DOC. THE ENTIRE FORM ONLY TAKES ME 15 MINUTES TO DO BECAUSE I USE ALOT OF YES/NO QUESTIONS. I ALSO COVER DX FOR POSSIBLE DECLINES IN ADL'S AND POTENTIAL FOR SKIN BREAKDOWN AND WHAT CURRENT INTERVENTIONS ARE TO PREVENT DECLINES. I TOUCH ON RESP/CARDIAC STATUS , WEIGHT CHANGES AND INTERVENTIONS. THE MAIN REASON I CAME UP WITH THIS FORM WAS BECAUSE SURVEYORS ON LAST VISIT WANTED TO KNOW EVERYTHING THAT WAS BEING DONE FOR PREVENTION RATHER THAN AFTER THE FACT AND I THOUGHT IT WOULD BE A GOOD TOOL TO HAVE THE INFO AVAILABLE IN ONE SPOT. BUT IT ALSO HELPS ME FOCUS MORE ON PREVENTION FOR INDIVIDUAL RESIDENTS.
welcome, kdhnursern and innes. This is a good place to share mds/careplan info.
bandaidexpert, BSN, RN
Fellow MDS Coordinators!!! I have found a truly wonderful software program for MDS's. It is called Answers on Demand. This program has cut my work in half. Of course, it has it's gliches, but don't they all? I come from the day when we wrote everything out by hand, the day the MDS was 15 pages long. This is a great program.
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