Table of Contents
GETTING STARTED
Job Description 1
Responsibilities 2
Education 3
Internet Resources 4
Online Web Reports 5
Scheduled Reports 7
Weekly Calendar 8
Using the Weekly Calendar 9
Resident Assessment Regulations 10
SCHEDULING
The Basics of Scheduling 13
Assessment Master Log 14
Using the Assessment Master Log 15
Monthly Assessment Calendar 16
Using the Monthly Assessment Calendar 17
MDS Completion Tracking 18
Using the MDS Completion Tracking Form 19
Status Update Memo 20
Using the Status Update Memo 21
Discharge and Reentry Tracking 22
Timeliness Criteria 23
Medicare Assessment Date Tracker 25
Medicare Tracker 26
Utilization Review 27
Medicare UR Census 28
Using the Medicare UR Census 29
MDS Assessment Scheduling Tool for 2010 31
DATA COLLECTION
Data Collection Made Easy 35
The Data Collection Form (MDS Cheat Sheet) 36
Using the Data Collection Form 38
Sources of Assessment Information 42
Care Area Triggers (CATs) 44
Sample CAT Documentation 47
CARE PLANNING
Care Conference Format 48
Care Conference Notes and Signatures 50
Care Plan Components 51
Care Plan Templates:
Care Plans are in Alphabetical Order
Blank Care Plan
Abusive, Physically
Blood Sugars, Unstable
Breathing Patterns, Ineffective
Cognitive Deficit, Decision-making
Cognitive Deficit, Memory Problem
Communication Deficit, Hearing
Communication Deficit, Speech
Constipation
Dental Care
Falls
Incontinence, Bowels
Incontinence, Urinary
Knowledge Deficit
Medication, Psychotropic
Pain
Physical Mobility, Ambulation
Physical Mobility, Bed Mobility
Physical Mobility, Locomotion
Physical Mobility, Range of Motion
Physical Mobility, Transfers
Prefers Own Routine
Rejects Care
Restraint
Self Care Deficit, Bathing
Self Care Deficit, Dressing
Self Care Deficit, Eating
Self Care Deficit, Grooming
Skin Breakdown
Tube Feeding
Urinary Retention
Visual Impairment
Weight Loss
QUALITY OF CARE
About Quality Indicators 94
Quality Indicators 95
Chronic Care Quality Measures 97
Revised QI/QM Reports 98
Surveys 100
The Quality Indicator Survey 101
CMS-82, Roster/Sample Matrix 102
CMS-672, Resident Census and Conditions of Residents 104
Consistency in Documentation 105
Nursing Assistant Care Form 106
Preventing Avoidable Declines 107
Significant Change in Status Checklist 108
Falls 109
Restraints 110
Skin Breakdown 112
Pain 113
Medications 114
MAXIMIZING REIMBURSEMENT
Increasing Reimbursement 116
Supporting Documentation for Medicare 117
Skilled Charting Guidelines:
Skilled Charting Guidelines are in Alphabetical Order
Behavior
Cardiac Care
Cognitive Impairment
Dehydration
Depression
Diabetes
Dialysis
Fever
IV Feeding
IV Medication
Occupational Therapy
Oxygen Use
Paralysis
Physical Therapy
Respiratory Therapy
Restorative Nursing
Speech Therapy
Tracheostomy Care
Tube Feeding
Vomiting
Weight Loss
Wound Care
RUG IV Score Information 140
RUG IV Categories 141
MDS Sections Changing Reimbursement 145
Physicians Orders / Visits Tracker 148
Using the Physicians Orders / Visits Tracker 149
REFERENCES AND RESOURCE DOCUMENTS
Glossary of MDS Terms and Acronyms i
Submitting MDS Assessments vii
Correcting the MDS ix
References xi