Sections A, C and D
Sections G and H
Sections I, J and M
Sections O and P
Miscellaneous
100
This is an important document found in the residents chart that is NOT considered a "Living Will" in MDS.
What is the Advanced Directives
100
In section G, this level of self performance reflects no participation by the resident at all. (not even a little, or even once)
What is 4 - Total Assistance. (If the resident was total care but participates once during their observation period in the activity, a code of 3 - extensive assistance would be appropriate.)
100
In section I these items are only coded if they are somehow 'Active' during the residents observation period.
What are diagnosis. TIP: (Code only those diagnosis that have a relationship to current ADL status, cognitive status, mood and behaviour status, medical treatments, nurse monitoring, or risk of death. (TIP: Also review the residents history, transfer records, consultation notes, CCAC documents etc.)
100
This type of medication can be counted in O1 so long as it is assumed to sustain a therapeutic blood level into the observation period.
What is a 'long acting' medication (ie. botox, B12 etc)
100
This type note must be written after you have unlocked and edited a MDS assessment which was previously locked indicating what you changed and why.
What is a Progress note. (TIP: Only click "re-open" on the section you wish to edit. To view a section without re-opening it click "view")
200
This section of "advanced directives" (A10) in the MDS is coded as "YES" when a residents Green Advanced Directives form says they are to remain in the facility in case of illness.
What is "Do not Hospitalize"
200
These Key people should always be consulted when you are coding sections G and H.
What are the HCAs. Other sections include B-cognitive status, E-Mood and Behaviors, J - Pain, P4 - Restraints
200
This section deals with this type of unpleasant sensation only which the resident ACTUALLY had experienced in their observation period.
What is pain. (TIP: Consult with resident and PSW, Review MAR, & progress notes)
200
The use of this device is coded if it restricts the resident and cannot be easily removed by the resident.
What is a restraint. (TIP: Even if only one bed rail is up, so long as the resident cannot remove it, you must code "other type of bedrails used" based on whether it was used less than daily -1 or used daily -2. If the resident can remove the device, do not count it as a restraint. We do not have "Full Bedrails". The reason a resident cannot remove a restraint, ie cognitive impairment, mobility limitations etc. does not impact the coding of this section.) Other notes: Seatbelt = truck restraint Laptray or tilted w/c = chair prevents rising Full bedrails = must cover 3/4 length of bed or more
200
This plan must be updated to reflect what has been coded in the MDS assessment.
What is the Care plan. TIP: The MDS is what helps you write the care plan since it is based on current resident needs and preferences, not the other way around. Although the language in the CP does not match the language used in the MDS for some sections Ie. ADL Self Performance, try to ensure they are as consistent as possible. When we start using the MDS library for the careplans in December the language will match between the two.)
300
This section is coded based on how well we are able to understand a resident, however they are able to communicate.
What is "Making self Understood".
300
This is what is "checked" when a resident remains in a reclined position for more than 22 hours of at least 4 of 7 days of their observation period.
What is "Bedfast all or Most of the Time"
300
This section is coded for the use of moisturizer, power, or barrier cream to protect skin or prevent skin breakdown.
What is M5i "Other preventative or protective skin care" (TIP: This item should always be coded for a resident who was coded as having episodes of incontinence)
300
This section of the chart should be checked for notes written by other health care providers/therapists, who delivered an assessment or treatment for a resident so the minutes can be coded by the nurse P1b
What is "consultation" or "progress note" (TIP: Check for assessments done by speak language pathologists, Psycho-geriatric consultants etc., also check PCC progress notes.) What is "Intervention programs for mood, behaviour, cognition loss".
300
These are the nursing sections of the MDS which can be coded prior to the ARD while the resident is still on observation.
What are sections C and D. (TIP: Remember, what you are coding is based on a specified look back period. If the MDS does not specify the look back period in the instructions for the question then use the 7 day observation period. While a resident is on 7 day observation is when you should examine their vision, hearing, oral and skin status because this is the time period you will be basing your coding on for these sections. You should also make a special effort to monitor residents on observation closely and note moods, behaviors, skin condition, use of restraints, gait, c/o pain, etc.
400
This is how a resident with cognitive impairment who is unable to state whether they have side vision or other visual disturbances would be coded in section D
What is "no" for both side vision problems and visual disturbances.
400
This plan, if it is documented in the care plan, would only be coded in section H if it has been helping the resident to 'stay dry'.
What is a "scheduled toileting plan". If a resident has a scheduled toileting plan but they are still frequently incontinent you will NOT code this item)
400
This type of device is coded if it is used in either the bed or chair and includes items such as air flow mattresses and roho cusions.
What is a "pressure relieving device" (TIP: Can be ANY device, so long as the purpose was for pressure relief)
400
This is the section where the nurse can code the time they spent with the resident setting up and monitoring a nebulizer or CPAP.
What is "respiratory therapy" P1bd (TIP: Column A "Number of days" is coded for days where the nurse SPENT 15 mins or more with the resident for the therapy. Column B is for "Total mins Spent". Hence it is likely that column A will be ZERO but column be "0014" respectively.
400
The little box beside THIS MESSAGE in the window that pops up under "view errors" must be "checked" (Acknowledged) before you can "sign off" on a section (make it green), if it appears.
What is the "Warnings List" or "Warning" (TIP: The warnings list are only flags of POSSIBLE discrepancies in the assessment. Read the warnings and "check" the box to acknowledge the warning(s), and click "Save acknowledged warnings". Then make appropriate changes to the assessment if necessary)
500
This type of resource person would need to be accessed to assess a residents ability to understand and to be understood when they speak and understand a language different than your own.
What is a Translator.
500
This is the item that is "checked" when a resident is lifted totally off the ground by the staff (No weight bearing by resident) when transfereing without a mechanical lift.
What is "Lifted Manually". TIP: This is only if the resident was completely lifted by staff.
500
This is how to code a diagnosis written in the blue sheet as "dementia" and no further information is documented in the chart.
What is "unspecified dementia" in I3. TIP: Check all available sources for more information first.
500
This is where the use of the Wander Guard bracelette can be coded in this section of the MDS.
What is P2d - Resident specific changes in environment to address mood or behaviour patterns. (TIP: Code this item for ANY CHANGES you had to make to the residents environment to address their mood or behaviour, even if only once. Ie. placing a non ambulatory restless resident near nursing station or applying a sensor alarm. Use of yellow door barriers to prevent resident from wandering into a specific room.
500
As long as the "assessment status" does not indicate that the assessment is ________ or "Accepted", it can be unlocked and corrected.
What is "Exported"
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