What is Nurse's MDS note?

[chocolate123]

Help! I'm a RN at a long term facility and I was asked to write MDS notes on my residents. What is MDS notes? Someone was telling me it is like write nurses notes, but you look at the care plan and write on each of the care plan. Is this right? Please advise.

[cadburypam]

What I write is a brief synopsis of the quarter. I.e. Resident showed no significant change, continues to require assist of 1 with completion of bathing, dressing and grooming. Ambulates ad lib with walker, uses wheelchair with staff assist for long distances. No falls this quarter. Treated for UTI x 1 with no further s/s. No behaviors exhibited. Care plans reviewed. Care plan conference scheduled for 00/00/08; family invited to attend.

Hope this helps.

[chocolate123]

Thanks canburypam! I think I have it....so all this time I have been writing it incorrectly.

[bluegeegoo2, LPN]

Our MDS nurses put together a "cheat sheet" that lists what they need us to write about. It helps quite a bit.

[pmw2007]

hello, I work nights in a LTC facility and sometimes I am at a loss as to what to chart. Most times I do not see the patients ambulating, or participating in their ADLs. They are sleeping. I also would like to be able to find a reference guide on rules &/or regulations of nursing requirements for nursing homes/ skilled nursing facilities. I have been nursing in LTC about 6 months, and I find it very confusing with all the requirements. I would like to have a better understanding of the requirements. I guess I need some background material on nursing , in nursing homes. Someone told me that the people in admissions actually get paid / admissions. Is this true? Thank you for any guidance.

[edhcinc]

Hi--the example given is a great one!

A note like this is needed because the MDS is currently not a "source" document. Unless the unit nurses write notes on a routine basis which indicate ADL or other observations which would support positive findings, the note "backs up" what is coded on the quarterly or annual.