pps documentation??

PPS documentation, Medicare charting, Nurses' notes__

https://allnurses.com/forums/showthread.php?s=&threadid=38146

Aaahhh ADLs...

There is no regulation from CMS to constrain facilities to religiously document what a resident does on a daily basis. Imagine nursing notes for each ADL function 3 shifts a day, 7 days a week, etc.

But if you want to be thorough, I can provide you with a hint...

For each resident with an upcoming MDS, provide a caregiver a score sheet (using the exact MDS numbers 0-4, also 8, incldg. the max. number of person assist) for each ADL function. Let them complete it before the end of the shift. Do this on all 3 shifts for 7 days ending on or before a projected ARD. At the end of the week, the nurse or MDS coordinator sums it up.

This is tedious task to start but works like a gem when used to.

If you know the resident pretty well, you can always indicate in their assignment sheets the type of help they should provide the resident to perform an ADL (again using the MDS lingo).

Good luck!

WE implemented a form that the Cna's fill out each day during the reference period. 7-3 filled out eating, 11-7 filled out bed mobility, 3-11 filled out transfers and toileting. These were the only ADL's we put on the form, not each and every ADL the MDS lists. We gave them an inservice, which also got their hours in for CEU's, used instructions from the MDS manual for them to review periodically that we placed in their flow sheet book and we placed the forms in that flowsheet book for the reference period and the form is working great. It has really gave us a clearer picture of what that resident has required in that period. For example, a resident that is usually independent in all ADLs was sick one day in the reference period and required more assist, we were able to know exactly what amount of care was needed that day.

another good site to check out is AANAC.org

Your nurses should also be documenting as to why the person is being skilled. If the pt is in for nursing reasons, what are they doing? Wound care? How much assist do they need? Tube feeding? O2? Nebs?

The therapists should be putting their notes in the chart on a timely basis and if you are using an early ARD, do you have hospital notes in that chart?

-Russell