SECTION A
SECTION I
SECTION O
SECTION P
Miscellaneous
100
This is an important green document found in the residents chart that is NOT considered a "Living Will" in MDS
What is the Advanced Directives
100
These are only coded if they are somehow 'Active' during the residents observation period.
What are diagnosis or Diseases. 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
Two different doses of the same drug are counted as how many
What is "one"
100
This item is coded to capture ALL treatment and dressing interventions that were used on a gastrostomy site.
What is "Ostomy Care" - P1af Any dressings to a trach would be captured under "trach care" P1aj
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) 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
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.
200
This is the MOST important document to review when you are completing section O of the MDS.
What is the MAR. (TIP: You are only counting medications which the resident actually took, therefore you will need to consult the MAR to see what was ACTUALLY TAKEN by the resident. Also, for section O there is a seven day look back period, note you will NOT be counting back seven days from today, but the 7 days of the observation period. (ARD and back 7 days)
200
The section "Abnormal Lab Values" pertains only what type of abnormal labs?
What are body substances.
200
In the warning list you must check the boxes next to the warnings and click ________ before you will be able to sign off that section.
What is "Save acknowledge warnings" (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)
300
If there is no document proof of a living will or organ donation request these items in the MDS would be coded as __________
What is No
300
This ______ must be present if you are adding a diagnosis in section I3 otherwise the diagnosis will not be recognized by CIHI
What is an ICD10 Code. (TIP: you can use an ICD 10 code to enter a more specific diagnosis than what is in I1. For example you can check off "Arthritis" in I1 and in I3 enter a ICD10 code for Rheumatoid arthritis. Also, in the pop up window of I3 you can click "Hot List" to bring up a list of the most commonly coded diagnosis)
300
Trazadone an antidepressant is often given as a hypnotic to help residents sleep is coded as an antidepressant because it is coded not by its intended use but by its ________.
What is Classification.
300
Hospital stays would be coded as this when the resident stayed in the ER once without being admitted to the hosptial.
What is zero. Hospital stays is only the number of times the resident was actually admitted to the hospital. It does not include ER visits or visits to the hospital for scheduled appointments. "Emergency room Visit" would be coded as 1.
300
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.)
400
In section A10, you can answer "unknown" only for what type of residents.
What are new Admissions.
400
This diagnosis would be "checked" in I1 if a resident has difficulty or is unable to speak or understand spoken word.
What is aphasia/dysphasia (if either receptive or expressive)
400
This is a popular topical cream used for painful and stiff joints and is counted as an analgesic.
What is A535 rub (TIP: Low dose aspirin (81mg) is counted as an analgesic).
400
This item is coded based on how many ______ the physican changed the orders.
What are "Days". -Number of "Days" the orders were changed. (TIP: Do not count order renewals without change. Do not count the number of changes, count the number of days a change occurred. Only count dietitian orders if they are signed by the physician.)
400
This is the reference date which you will counting back from to determine the dates which you will base your coding on in the MDS assessment.
What is the ARD. The ARD is the last day of the observation period. In the MDS, each question usually indicates what the look back period is, ie 7 days, 14 days, 30 days, 90 days, etc. If it does not specify, then use the 7 day observation period.
500
Which level of care would most likely require "Treatment Restrictions" to be coded as YES in A10 (advanced directives)
What is level 1
500
This diagnosis would be checked if the resident has one sided weakness or paralysis
What is w-Hemiplegia/Hemiparesis. Also note that "Allergies" in I1 can be checked if the resident has any known allergies.
500
This type of medication can be counted in O1 even if it was given outside of the observation period so long as it is assumed to sustain a therapeutic blood level into the observation period.
What is a 'long acting' medication.
500
In addition to being performed in the nursing home, any item in section P1a-l could be coded if it was performed "where" as well.
What is the Hospital.
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" (Only click "re-open" on the section which you want to edit or correct, otherwise to simply look at a section click "view")
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