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Question: I am reviewing a medical record for a denied claim. The notes from staff interviews regarding levels of assistance for late loss ADLs were utilized to code two-person assist. Two-person assist was not coded on the ADL charting grids. Are these interview notes considered part of the medical record? Can these notes be utilized for coding on the MDS?
Answer: From pages 1-7 of the RAI User’s Manual
The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that
(1) the assessment accurately reflects the resident's status
(2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals
(3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.
Looking at #3, communication with the resident and direct care staff..................This would need to be documented in the medical record to include this information on the MDS. The MDS answers should be reproducible within the medical record (with the exception of the interview questions which are self-supporting).
Also, from G-3
Steps for Assessment
1. Review the documentation in the medical record for the 7-day look-back period.
2. Talk with direct care staff from each shift that has cared for the resident to learn what the resident does for himself during each episode of each ADL activity definition as well as the type and level of staff assistance provided. Remind staff that the focus is on the 7-day look-back period only.
3. When reviewing records, interviewing staff, and observing the resident, be specific in evaluating each component as listed in the ADL activity definition. For example, when evaluating Bed Mobility, observe what the resident is able to do without assistance, and then determine the level of assistance the resident requires from staff for moving to and from a lying position, for turning the resident from side to side, and/or for positioning the resident in bed.
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