What is Nurse's MDS note?

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.

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

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

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.

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.