Having hard time coding Section G

Does anyone use therapy evals for Section G?

According to the OIG that just reviewed our charts, restorative and therapy should be used as supportive documentation to determine ADL function. The previous MDS coordinator would not use them one example was she would code w/c bound but therapy would code walking with walker assist. Needless to say we lost $$$.

We always take therapy info/participation into consideration - especially for ambulation.

Wow, my company says don't use therapy documentation, but I have to for walking because it's not on our ADL documentation sheets. Our corporate guy says absolutely NO, but there is no other documentation. What to do? At this point I will use any documentation I can find in the record. I spend HOURS looking for documentation sometimes.

It seems that the Therapy notes reflect what the resident can TRULY be capable of. We nurses are trained from day 1 to make every accommodation for our patients and we just naturally see them as functioning lower than they really are. The therapists on the other hand cue the patient to do those things on their own and I often see a discrepancy of function between the nurses documentation and the therapists.

Therapy is looking at the resident at his best for documentation. MDSs are coding them at their worst. If a resident is coded during the day as a 2/2 but on nights they are a 3/2 for 4 days during the look-back period, using the rule of three's, they would be coded as a 3/2. Therapy documentation can be used to write care plan goals.

I've been working with my CNAs on ADL coding to try to get better data.

We have developed a "Med-A" form for the charge nurse to fill out every shift on our Med-A residents. This allows them to document things like Section G. Its funny because every shift comes up with something different. Personally, I just ask the CNAs on the hall how they are, or I will observe them myself. Its really hard sometimes to rely on other documentation, especially when its not been done right.

Remember, too, that therapy gets them nice and early when they're bright-tailed and bushy-eyed, and nursing gets them at the end of the day after therapy has inflicted their pain and torture and they're 3/3 for everything including eating. Most of them DO fluctuate depending on the shift....