MDS 3.0 Data Collection Tool?

I make copies of blank MDS relevant items for each discipline such as b-e for social services, k for dietary, etc and hand them out to the individual who will do the assessments after indicating the ARD on the forms. Thsn I have a cheat sheet I use for infor from the computer. I could send it to you, if you give me your email addy.

name:_____________________________________

ard:________ 7 back:________ 14 back:________

lastmds ard/type:__________________________

bims:________/________ mood:________/________

pain:____________________/__________________

(sect.i) active diagnosis list:

________________________________

uti past 30 days? y n

since last assessment? y n date:________________

medicationsused/taken (in past 7 days)

___________________________________________

sect.j: (in past 7 days) sob w/ exertion

sob @ rest sob whenlaying flat hospice/terminal fever vomiting

j01800 falls (since admit or last assessment)

no injury_________ minorinjury_________

major injury_________

dates:_____________________________________

sect.k: (in past 7 days)

diet:_______________________________________

weight:_____________ height:____________

bmi:________________

supplements:________________________________

sect.m: (in past 7 days)

askin report/treatment book for pressure ulcers, skin tears, incont. skin relatedproblems, surgical wounds, etc.

sect.n (in last 7 days)

# of days injectionsgiven:_____________

# of days insulingiven:______________

# of days phys. changedinsulin orders:___________

# of days these meds used in past 7 days:

antipsychotic_____ antianxiety_____ diuretic_____ antidepressant_____ hypnotic_____ anticoagulant_____ antibiotic_____

sect.o (in last 14 days) while not a resident

chemo radiation oxygen suction trach vent/respirator bipap/cpap ivmed transfusion dialysis hospice isolation(strict)

sect.o (in last 14 days) while a resident

chemo radiation oxygen suction trach vent/respirator bipap/cpap iv med transfusion dialysis hospice isolation(strict)

flu shot:______________ pneumo:______________

physicianexam/visits (in the past 14 days)

___________________________________________

phys. orders (in the past 14 days)

*not clarifications or readmit orders

___________________________________________

sect. p restraints used inthe past 7 days: y n

used daily or notdaily?

type:_____________________________________

othernotes, etc. can go on the back side