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Discussion

Is a RAP Summary needed?

When I first started at my facility, I was trained to do a Narrative RAP Summary for every RAP triggered which had been a very lenghty ordeal, but we were doing the care plans by hand at that time too.. We started doing the Patient Care Plans in the EMR and I am so blessed to work with great nurses who take pride in their Care Plans. But then it occured to me that I may be wasting time writing out the long, lengthy narrative summaries if I am already documenting the location in the Care Plan in the CAA Summary. Is there any need to do the narrative summaries if I am already putting the location of the triggers in the CAA?

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    rai p4-7

    written documentation of the caa findings and decision-making process may appear anywhere in a resident's record; for example, in discipline-specific flow sheets, progress notes, the care plan summary notes, a caa summary narrative, etc. nursing homes should use a format that provides the information as outlined in this manual and the state operations manual (som). if it is not clear that a facility's documentation provides this information, surveyors may ask facility staff to provide such evidence.

    if the "format" of the care plan contains...

    • identified triggered caas
    • analyzed triggered caas
    • decision-making and caa documentation

    .. then you are already in compliance.

    since the care plan is only a summary itself, it would be beneficial to cite other locations, e.g. -- aside from "see cp 9/1/11", add "see dietitian's prog notes 8/24/11, psych consult 8/26". don't wait for that surveyor to ask for "evidence".

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