Table of Contents
GETTING STARTED
Job Description 1
Responsibilities 2
Education 3
Internet Resources 4
Start-up Information 5
Submitting MDS Data 6
Online Web Reports 7
Scheduled Reports 8
Work Calendar 10
Using the Work Calendar 11
Resident Assessment Regulations 12
SCHEDULING
The Basics of Scheduling 15
Assessment Master Log 16
Using the Assessment Master Log 17
Monthly Assessment Calendar 18
Using the Monthly Assessment Calendar 19
MDS Completion Tracking 20
Using the MDS Completion Tracking Form 21
Status Update Memo 22
Using the Status Update Memo 23
Discharge and Reentry Tracking 24
MDS Completion Dates for OBRA 25
MDS Completion Dates for Corrections 26
Medicare Assessment Date Tracker 27
Medicare Tracker 28
Medicare UR Census 30
Using the Medicare UR Census 31
MDS Completion Dates for PPS Assessments 32
MDS OBRA Assessment Scheduling Tool for 2008 33
DATA COLLECTION
Data Collection Made Easy 33
The Data Collection Form (MDS Cheat Sheet) 34
Using the Data Collection Form 36
Sources of Assessment Information 42
MDS Sections filled out by IDT Members 44
Documenting the RAP Process 45
CARE PLANNING
Care Conference Format 46
Care Conference Notes and Signatures 48
Care Plan Components 49
Care Plan Templates:
Blank Care Plan 50
ADL / Bathing / Self Care Deficit 51
ADL / Dressing and Grooming / Self Care Deficit 52
Anemia / Activity Intolerance 53
Aspiration / Potential for Injury 54
Blood Sugars / Unstable / Altered Health Maintenance 55
Breathing Patterns / Ineffective 56
Cognitive / Alteration in Thought Processes 57
Communication / Impaired 58
Constipation 59
Diarrhea 60
Falls / Risk for Injury / Potential for 61
Fluid Volume Deficit 63
Fluid Volume Excess 64
Incontinence 65
Insomnia / Sleep Pattern Disturbance 66
Knowledge Deficit 67
Pain 68
Physical Mobility / Impaired 69
Psychotropic Medication / Potential for Side Effects 70
Restraint / Potential for Injury 71
Skin Integrity / Impaired 72
Urinary Retention 73
Visual Impairment 74
QUALITY OF CARE
About Quality Indicators 75
The 24 Quality Indicators 76
Quality Measures 78
Enhanced Quality Measures 80
Surveys 81
CMS-82, Roster/Sample Matrix 82
CMS-672, Resident Census and Conditions of Residents 84
Consistency in Documentation 85
Nursing Assistant Care Form 86
Preventing Avoidable Declines 87
Falls 88
Restraints 90
Skin Breakdown 91
Pain 92
Medications 93
MAXIMIZING REIMBURSEMENT
Increasing Reimbursement 95
Supporting Documentation for Medicare 96
Skilled Charting Guidelines:
Behavior 97
Cardiac Care 98
Cognitive Impairment 99
Dehydration 100
Depression 101
Diabetes 102
Dialysis 103
Fever 104
IV Feeding 105
IV Medication 106
Occupational Therapy 107
Oxygen Use 108
Paralysis 109
Physical Therapy 110
Respiratory Therapy 111
Restorative Nursing 112
Speech Therapy 113
Suctioning 114
Tracheostomy Care 115
Tube Feeding 116
Vomiting 117
Weight Loss 118
Wound Care 119
RUG Score Information 120
RUG Categories 121
MDS Sections Changing Reimbursement 124
Significant Change in Status Checklist 129
Physicians Orders / Visits Tracker 130
Using the Physicians Orders / Visits Tracker 131
Data Assessment and Verification Project 132
GLOSSARY
Glossary of MDS Terms and Acronyms i
REFERENCES AND RESOURCE DOCUMENTS
Protecting the Privacy of MDS Data iv
Correcting the MDS vii
Reproduction and Maintenance of the Assessments viii
References x
Index of Forms xi