Our software is Keane care, and we have a section for IPNs in addition to the Assessment and Care plan sections. We each type our IPN (activity, nursing, SS, and dietary) and then print them out and put them in the chart with the paper copy of the MDS. My section covers pain, new medications and medical issues, mobility, G items, bowel and bladder, skin, infections, falls, rehab, etc. I summarize the quarter, or shorter for medicare 5, 14, 30 days. Our surveyors seem to like the summary, except when I neglect to mention a fall, or accidentally write that someone is independent instead of supervised!
I just discussed with our state rep about referencing the IPN instead of writing a RAP documentation note explaining each RAP. She stated it would be fine...and it would eliminate the duplication. So now, on the CAA summary, I will write "see IPN dated 10/9/10 DW (my initials)" instead of "CAA documentation note." All of my team are happy with this as we now are writing the IPN (which takes about 45 minutes each) and doing RAP or CAA documentation notes too. I have been the MDS coordinator for just over a year and found in our last survey that this seems to answer a lot of the questions before the surveyors have to ask for additional info. I hope this helps you. Also, I have changed my original worksheet as I have done more MDSes. Is there a way to post it in a message if I am not a GOLD member in allnurses? I suppose I should just officially join, but I just don't seem to get around to it!