The job of the nurse assessment coordinator is not a simple one. The MDS is 47 pages long, which means that, depending on how many residents are currently living at the facility, the nurse assessment coordinator (NAC) could be collecting data for and filling out several hundred electronic pages on a weekly basis. (And that’s a conservative estimate.)
That’s why Jessie McGill, RN, RAC-MT, and AANAC curriculum development specialist, created the MDS Data Collection Tool for NACs—to help NACs streamline the MDS coding process, stay organized, and complete their work more efficiently.
The tool consists of only three pages. The first two pages are to review data from the medical record, and they’re completed after the assessment reference date (ARD) of the MDS assessment. The third page is for noting observations during the MDS scripted interview.
The concept behind the tool is to have a single, easy-to-review location that houses all the information you need when filling out the MDS, so that you don’t have to constantly go back to comb through the medical record, which can be cumbersome and time-consuming. The data collection tool has sections for each of the look-back periods, medication administration, therapy and nursing documentation, and the treatment and restorative records.
“One of the most frustrating things when you’re a NAC is when you complete the chart review and you go to code the MDS, only to realize you did not write down enough information. For example, if you recall reading that the resident had a fever, but you cannot recall if the documentation occurred during the 7-day look-back period, so you have to go back and review that entire look-back period again to find the documentation. The data collection tool helps to ensure that you are very inclusive when you are completing the chart review,” says McGill.
Here are five simple steps for using the MDS charting tool to set yourself (and your MDSs) up for success:
1. Understand the importance of timing
It’s important as you’re using the tool to understand the timing as it pertains to conducting scripted interviews, observing the resident and his or her room, and completing the chart review.
As such, you’ll actually be completing the third page of the assessment tool first; as mentioned above, this page is for use during the scripted interviews and the resident/room observation.
· MDS scripted interviews must be completed, coded on the MDS, and signed on or before the ARD.
· Resident and room observations must be identified and documented in the medical record on or before the ARD, and within the look-back period.
This latter item includes observations that you made as a nurse during the scripted interview, observations that can serve as supporting documentation.
Let’s say, for instance, that during the interview, the resident complained of shortness of breath, or you noticed that the resident was sleeping with the head of the bed elevated. You can inquire whether that elevation is to facilitate breathing. If so, you want this documented in the medical record so it can be coded appropriately as shortness of breath while lying flat.
This is also the time to double-check that the resident’s glasses and hearing aid are in place, to observe whether the resident’s speech can be understood, and to look for signs and symptoms of delirium. The worksheet provides space to take relevant notes.
“The process of room observation can really help start a necessary dialogue with other IDT members. We may notice that the resident now has side rails or a mat on the floor. Observing these kinds of interventions can lead us to asking important questions: Is the care plan up to date? What are these items for? Are they still appropriate? Is it possibly a restraint? Is the restraint assessment form completed? So it really looks at the big picture of what's going on in the resident’s environment, as well as any other information that the resident may share with us during that interview,” says McGill.
Once you’ve completed the third page of the data collection tool, you'll move onto pages 1 and 2, which contain the chart review portion and must be completed after the ARD, to include all information that occurred up until midnight of the ARD.
2. Know your look-back periods
The NAC works with three main look-back periods for the chart review: the 5-day, 7-day, and 14-day. You will enter the resident’s name and the ARD for this assessment on page 1, and the tool will auto-populate the correct look-back periods throughout the worksheet. (This is the only part of the tool that is interactive.) You can then print the worksheet out and fill in the remainder of your information by hand.
While most MDS items collect data only for what occurred after admission to the facility, some items have a look-back period that extends prior to admission or reentry. These items are coded in some sections as “while not a resident,” such as item O0100, or the coding instructions may indicate “prior to admission/entry or reentry,” such as J1700.
This tool will help guide you to collect necessary information before and/or after entry or reentry to the facility and within the appropriate look-back periods.
One example of an MDS item that is coded both before and after admission/entry or reentry is the administration of oxygen.
“If the resident had oxygen administered in the hospital before admission to the facility and within the 14-day look-back period, we would code this at O0100C, column 1, ‘while not a resident,’” says McGill.
3. Have a systematic process for gathering data from all sources
When collecting data for the MDS, you will often have to source data from multiple areas within the medical record. One example of this is the activities of daily living (ADLs).
Typically, nurse aides will document ADLs throughout their shift, ideally for each episode of care. However, this should not be the only documentation source used to support MDS coding for G0110. The nurse, too, may have documented in her notes how the resident performed during an ADL activity, such as a transfer or bed mobility, that she assisted with. The therapist may have also documented how the resident performed in an ADL task, such as ambulation in the room, in the daily therapy progress notes. All of this data must be included when coding the MDS.
“It's important to look at all of the sources that may contain information regarding each MDS item,” says McGill.
The data collection tool guides you through many of the sources from which you may need to gather information: the IDT progress notes, documentation made by nurse aides, treatment and medication administration records, restorative records, therapy notes, and diagnosis records. However, developing your own systematic process will help streamline these steps, making the data collection more efficient and ensuring that it’s comprehensive.
4. Transfer the data
And it really is that simple. The data collection tool notates in each section the correlating item of the MDS that you have to code, so you simply have to transfer the data from your tool to the MDS.
“You can easily find exactly where on the MDS an item needs to be coded, which helps prevent inaccuracies due to planning to go back and add something later,” says McGill.
5. Remember, it’s just a worksheet
It’s important to bear in mind that this worksheet is not an official document; it is merely a tool to the process of MDS coding. Its purpose is to be printed off, collect the data, streamline the process, and then be shredded. All supporting documentation must be found within the resident’s actual medical record.
When used correctly, AANAC’s MDS Data Collection Tool can be a valuable asset to you as a NAC. To access the tool, click here.
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