Inadequate documentation

[dian57]

Our facility is trying to develop a system for adequate MDS documentation. We have tried posting diagnosis driven cheat sheets (document on at least 2 of these items/shift) posted on the chart and a check-off flowsheet with lines on the back for narrative notes. We have revised our CNA documentation flowsheets to reflect MDS language. Our 2 year trial of EMR CareTracker was a disaster and we have returned to paper.

It seems no matter how much inservicing, reminding, checking, reinforcing we do, our documentation is not there or inaccurate many times. Each time I do an MDS I get one set of information from the CNA sheets, another from the nurses notes and yet a different picture from staff/family interviews.

Has anyone successfully managed a way to obtain consistant and accurate documentation in the record?

[miccay]

This is a constant battle at my facility also. We have been using Caretracker since March and we have inservices frequently on correct coding. I don't have any advice on how to successfully obtain a consistant and accurate documentation record, but I do believe the CNAs are your best of information since they work one on one with the residents. You have to talk with all shifts to get the whole picture.

[caliotter3]

Your supervisors should address this in performance evaluations. I have worked for more than one employer who called people in to clean up their charting on their own time. Enough trips back to the job to get it right usually helps improve matters.

[Ginger's Mom, MSN, RN]

You need to explain inconsistent charting is falsifying a patient record. It is lying and unethical. Upper management needs to get involved.

[lorijoas]

Our facility is trying to develop a system for adequate MDS documentation. We have tried posting diagnosis driven cheat sheets (document on at least 2 of these items/shift) posted on the chart and a check-off flowsheet with lines on the back for narrative notes. We have revised our CNA documentation flowsheets to reflect MDS language. Our 2 year trial of EMR CareTracker was a disaster and we have returned to paper.

It seems no matter how much inservicing, reminding, checking, reinforcing we do, our documentation is not there or inaccurate many times. Each time I do an MDS I get one set of information from the CNA sheets, another from the nurses notes and yet a different picture from staff/family interviews.

Has anyone successfully managed a way to obtain consistant and accurate documentation in the record?

If it makes you feel better our facility has electronic documentation and still is not adequate to answer all the questions on the MDS and nurses waste their time answering questions that are not used.