MDS Documentation Guidelines for floor nurses

Unfortunately my facility does not have such a thing for the regular residents - only for the medicare ones. They don't even know when the residents are in an observation period!! We usually don't get much help from their charting.

I know some facilties have the residents names posted when their in their observation window, then have listed information that you want them to chart on. (ie: pain, vomiting, fever, SOB, behaviors)

In our home, we flag the spine of the chart with a sticker that gives the dates of the 7 day look-back period. Staff then knows that they must give better attention to charting such things as pain, ADL's, cognition, etc. and we also have the rehab staff put out the 7 day look back records for the CNA's to chart ADL abilities. A chart with dates for interviews is put out with the MDS and careplan schedule. That way, no one is NOT aware of when these are expected. So far, so good. It takes a bit of time to do this, but good compliance is achieved.

I have a LTC resident who hasn't been charted on since August. This is more challenging than I expected

Our skilled charting is so poor that is another issue in and of itself. Any ideas or suggestions would be much appreciated.

med-pass.com has many sample forms that you can review and either order, or get ideas to make your own forms/templates.

I realize that the comment I am responding to is from 2010, but does anybody have any templates,cheat sheets for teaching the floor nurses what documentation is needed for MDS, for both Med A and LTC. I hope there are some new forms since 2010! Thank you!!

Just remember that there are interviews and assessments that the MDS Coordinator should do, i.e., the pain interview, the dental assessment (Section L), etc. It is fine to have the floor nurses gather some of the information, but.......you are responsible for the accuracy of it. So if the floor nurse completes the fall assessment during the lookback period and she says there were no falls since the last assessment; yet the resident had a fall with injury, and you use the fall assessment to complete your MDS instead of reviewing the chart yourself, YOU are responsible for making sure the MDS is coded accurately. We have a resident who is blind in one eye and has highly impaired vision in the other eye. Amazing how most of the daily Medicare charting says her vision is adequate with her glasses.

You will get a routine down that will make it easier for you.

Thank you.