Having hard time coding Section G

Specialties MDS

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Specializes in mds coordinator.

I feel like I am always confused and not sure while coding Section G. Plus nurses notes make my coding more difficult bec i am getting more confused with them. Do u have suggestions to make coding section G more accurate. When i am very confused i just go to bedside then observe resident with their bed mobility, transfers, etc but end up not matching with what nurses document. Any comment, suggestions is very muc appreciated.Thanks.

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Specializes in Long term care.

In my building, the nurses wouldn't know every ADL need of the resident, so we go to the CNA's for clarification. We also have a Restorative nurse that is assisting in the section G area coding.

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Specializes in gerontology.

do you have CNA charting for restorative or ADL programs? do you have a Rehab nurse? If not, then you should devise some sort of tool that the CNA can code for ADL's during the assessment 7 day look-back. Its vitally important to get ALL SHIFTS input, not just days. You can purchase preprinted forms that the CNA's fill out for the ADL section from Briggs and MedPass to name a couple. Go visit theuir websites.

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Specializes in MDS/Office.

We pull the ADL's from our Computer System.

I would NOT take it upon myself to code the Late Loss ADL's.

Any MDS Coordinator validating Late Loss ADL's is asking for Trouble! ;)

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Specializes in LTC, WCC, MDS Coordinator.
do you have CNA charting for restorative or ADL programs? do you have a Rehab nurse? If not, then you should devise some sort of tool that the CNA can code for ADL's during the assessment 7 day look-back. Its vitally important to get ALL SHIFTS input, not just days. You can purchase preprinted forms that the CNA's fill out for the ADL section from Briggs and MedPass to name a couple. Go visit theuir websites.

But you are still getting information only as good as the CNA. Ours do ADL sheets daily but it seems that the first person to code anything sets the stage. Everyone else just seems to copy what was put there the day before. So, if they coded it wrong the first day, it just is wrong the whole month. Wish I could fix this!

If I see that the coding doesn't reflect the real way the resident is, I do a short note about what was observed during assessments and interviews. Hope it doesn't look bad since I'm the one doing the MDS's and also finding incorrect charting.

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Specializes in Long term care.

We too find the copy cat charting for ADL's by the CNA's. I still wonder what a 1/3 is supposed to mean.....LOL.

Wish we could put a new sheet out daily, to stop the copy cat stuff, but it's just not feasible. Our CNA's will be getting another inservice on the coding next week.

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Specializes in MDS Coordinator.

We pull our ADLs from the computer. I get some funny coding if I were to follow the rules exactly as they are laid out. For example, there has been a number of times I"m getting a 0/2 for bed mobility and transfers?

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Specializes in Assessment coordinator.

I finally had to start looking at the CNA ADL sheets several times a week. I personally trained all the CNA's (60+ of them) and now I will put a post-it on a sheet when I see someone copycatting something wrong, with something sarcastic like, "Really, he feeds himself?" and I sign it. They make a BEELINE for my office when they find my notes, and let me know what they are thinking, and how would I like them to chart what they are doing. It really works because even though I say horrible things, they know I am totally approachable and I love to teach. The time commitment for the first week was out rageous, but now I usually don't spend ten minutes a day on correcting their charting. It has really picked up the two person assist, as well. I accused them of not ever working together, and of using mechanical lifts with only one person (Against company policy.) They cleaned it up.

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Specializes in LTC, Hospice, Case Management.
I finally had to start looking at the CNA ADL sheets several times a week. I personally trained all the CNA's (60+ of them) and now I will put a post-it on a sheet when I see someone copycatting something wrong, with something sarcastic like, "Really, he feeds himself?" and I sign it. They make a BEELINE for my office when they find my notes, and let me know what they are thinking, and how would I like them to chart what they are doing. It really works because even though I say horrible things, they know I am totally approachable and I love to teach. The time commitment for the first week was out rageous, but now I usually don't spend ten minutes a day on correcting their charting. It has really picked up the two person assist, as well. I accused them of not ever working together, and of using mechanical lifts with only one person (Against company policy.) They cleaned it up.

I love when they code my double amputee with no prosthesis as a 3/2 for walking. Also love the 3/3's for eating. I also tend to get a little sarcastic with them. "Hey, when you get ready to walk Mr Smith today can you come get me so I know how it's done". (Their reply..."WHAT...you know he can't walk) "Really then why are you coding 3/2"???

Then into the dining room for the demonstration of 2 person assist for eating - Asked "So how does this work...one hold their nose while the other shovels food"? Couple of my best CNA's later came back at me (after much thinking & with a happy sarcastic attitude)..."well ya see, the nurse was giving the tube feeding while we gave her a bite of her pleasure feeding". Cracked me & they were just kidding with me. Smart orifices they are.

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Specializes in GERIATRIC.
I feel like I am always confused and not sure while coding Section G. Plus nurses notes make my coding more difficult bec i am getting more confused with them. Do u have suggestions to make coding section G more accurate. When i am very confused i just go to bedside then observe resident with their bed mobility, transfers, etc but end up not matching with what nurses document. Any comment, suggestions is very muc appreciated.Thanks.

We have ADL sheets for the CNAs to fill out that match the MDS exactly. Our nurses use them to chart and we gather our information to fill out section G from them

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Specializes in Med surg, LTC, Administration.
I finally had to start looking at the CNA ADL sheets several times a week. I personally trained all the CNA's (60+ of them) and now I will put a post-it on a sheet when I see someone copycatting something wrong, with something sarcastic like, "Really, he feeds himself?" and I sign it. They make a BEELINE for my office when they find my notes, and let me know what they are thinking, and how would I like them to chart what they are doing. It really works because even though I say horrible things, they know I am totally approachable and I love to teach. The time commitment for the first week was out rageous, but now I usually don't spend ten minutes a day on correcting their charting. It has really picked up the two person assist, as well. I accused them of not ever working together, and of using mechanical lifts with only one person (Against company policy.) They cleaned it up.

Now this is the way to get it done...right! :yeah:

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Does anyone use therapy evals for Section G?

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