Does anyone have a template or guide for monthly nursing notes? My facility would like to try something new and we are looking for ideas.
Nov 17, '09
HI. I have been doing MDS's since OBRA went through. monthly summaries are meaningless. Especially the check off type. What i have done (& received kudo's from the state) are quarterly updates which basically covers the care plan. I begin with CODE status, discharge plan/potential, MD last visit and any othe disciplines (Podiatrist, DDS, Ocular). I the move thru the care plan, commenting on goals, describing the resident & what he is able to do at this time. I include weights & BMI. change in MD orders, Falls or injuries, skin condition. I coinside these updates with are basically reviewing the RAPS with the quarterly MDS. These updates also more or less back up the MDS. I also review the documentation of SS, Dietary, Activities, & Rehab I use these updates at the Care Plan Conferance with the other disciplines. This way the plan of care is reviewed. It works for us. We have great surveys.