I'm a R.D. working in LTC and responsible for 100% of the documentation, MDS, care plans, etc. I do not have a DTR or CDM. 140 bed facility. My question is this-- what is the timeframe for actual MDS charting in the medical record? I am familiar with the timeframe for entering the MDS/CAAS in the database, but I'm uncertain as to actual documentation in the medical record. Could someone clarify "due dates" for the actual RD charting in the medical record? When the MDS is entered in the database, how long does the RD have to actually write a note in the actual record? Please help. I would love to see a document or reference that lays it all out nicely for me. lol

I'm a R.D. working in LTC and responsible for 100% of the documentation, MDS, care plans, etc. I do not have a DTR or CDM. 140 bed facility. My question is this-- what is the timeframe for actual MDS charting in the medical record? I am familiar with the timeframe for entering the MDS/CAAS in the database, but I'm uncertain as to actual documentation in the medical record. Could someone clarify "due dates" for the actual RD charting in the medical record? When the MDS is entered in the database, how long does the RD have to actually write a note in the actual record? Please help. I would love to see a document or reference that lays it all out nicely for me. lol

This may differ from facility to facilty but we do not need to write a note everytime and MDS is done. A full assessment must be done within 14 days of admission, in my opinion that is way too long to go without any documentation. We do all of our assessments within 24 hours, or within 3 business days if admitted on a Friday. We follow up with all admissions x 1 month and then quarterly if stable. In my facility quarterly's are done every 2 months. Some of our rehab patients are documented on weekly depending on their wts. HD patients and Tubefeeders are usually documented on monthly. Hope that helps.

This may differ from facility to facilty but we do not need to write a note everytime and MDS is done. A full assessment must be done within 14 days of admission, in my opinion that is way too long to go without any documentation. We do all of our assessments within 24 hours, or within 3 business days if admitted on a Friday. We follow up with all admissions x 1 month and then quarterly if stable. In my facility quarterly's are done every 2 months. Some of our rehab patients are documented on weekly depending on their wts. HD patients and Tubefeeders are usually documented on monthly. Hope that helps.

Thank you! What about actual timeframe, however? Let's say resident Joseph has a quarterly MDS due- his ARD date is 5/16. My facility requires an actual note written. When do I write the actual note in the medical record? Would it be during 5/9-5/16? I am so confused. I'm sorry if I confuse you, too! :-(

Thank you! What about actual timeframe, however? Let's say resident Joseph has a quarterly MDS due- his ARD date is 5/16. My facility requires an actual note written. When do I write the actual note in the medical record? Would it be during 5/9-5/16? I am so confused. I'm sorry if I confuse you, too! :-(

This is based on your facility time frame. What you are really asking is what will the state surveyer expect to see. Write your notes within the ARD and place in the chart. It sounds a little like you are double documenting and causing extra work. At my facility I use an assessment form that follows the MDS questions and CAA's for section K. When I complete the form it is placed in the chart as my nutrition note. Happy to share the form/nutriton assessment. I am in a similar situation with no help from supporting staff.

This is based on your facility time frame. What you are really asking is what will the state surveyer expect to see. Write your notes within the ARD and place in the chart. It sounds a little like you are double documenting and causing extra work. At my facility I use an assessment form that follows the MDS questions and CAA's for section K. When I complete the form it is placed in the chart as my nutrition note. Happy to share the form/nutriton assessment. I am in a similar situation with no help from supporting staff.

Thank you, sewest! Oh- I am 100% certain that I double document! Probably triple document! Thank you so much for your input.

Thank you, sewest! Oh- I am 100% certain that I double document! Probably triple document! Thank you so much for your input.

Sewest, Would you mind to share that documentation tool you mentioned? That would be fantastic! TY.

Sewest, Would you mind to share that documentation tool you mentioned? That would be fantastic! TY.
Posted by dietwhisperer:
Sewest, Would you mind to share that documentation tool you mentioned? That would be fantastic! TY.
Happy to share but I don't know how to do that from this thread. Can you give me your email address?
Posted by dietwhisperer:<BR>Sewest, Would you mind to share that documentation tool you mentioned? That would be fantastic! TY. Happy to share but I don't know how to do that from this thread. Can you give me your email address?

Hello, would you be able to share that documentation tool with me as well. Seems like it'll be very helpful for me. You can email at sweetpain10@gmail.com. Thanks

Hello, would you be able to share that documentation tool with me as well. Seems like it'll be very helpful for me. You can email at sweetpain10@gmail.com. Thanks

Cam I get a copy of your form as well. Sounds like a perfect tool to use wolfpierce@aol.com

Cam I get a copy of your form as well. Sounds like a perfect tool to use wolfpierce@aol.com
Posted by sewest:
This is based on your facility time frame. What you are really asking is what will the state surveyer expect to see. Write your notes within the ARD and place in the chart. It sounds a little like you are double documenting and causing extra work. At my facility I use an assessment form that follows the MDS questions and CAA's for section K. When I complete the form it is placed in the chart as my nutrition note. Happy to share the form/nutriton assessment. I am in a similar situation with no help from supporting staff.
Posted by sewest:<BR>This is based on your facility time frame. What you are really asking is what will the state surveyer expect to see. Write your notes within the ARD and place in the chart. It sounds a little like you are double documenting and causing extra work. At my facility I use an assessment form that follows the MDS questions and CAA's for section K. When I complete the form it is placed in the chart as my nutrition note. Happy to share the form/nutriton assessment. I am in a similar situation with no help from supporting staff.
Posted by lovey:
Posted by sewest:
This is based on your facility time frame. What you are really asking is what will the state surveyer expect to see. Write your notes within the ARD and place in the chart. It sounds a little like you are double documenting and causing extra work. At my facility I use an assessment form that follows the MDS questions and CAA's for section K. When I complete the form it is placed in the chart as my nutrition note. Happy to share the form/nutriton assessment. I am in a similar situation with no help from supporting staff.
here is my email dietitianhighland 1114@yahoo.com
Posted by lovey:<BR>Posted by sewest:<BR>This is based on your facility time frame. What you are really asking is what will the state surveyer expect to see. Write your notes within the ARD and place in the chart. It sounds a little like you are double documenting and causing extra work. At my facility I use an assessment form that follows the MDS questions and CAA's for section K. When I complete the form it is placed in the chart as my nutrition note. Happy to share the form/nutriton assessment. I am in a similar situation with no help from supporting staff.here is my email dietitianhighland 1114@yahoo.com
Posted by sewest:
Posted by dietwhisperer:
Sewest, Would you mind to share that documentation tool you mentioned? That would be fantastic! TY.
Happy to share but I don't know how to do that from this thread. Can you give me your email address?
Posted by sewest:<BR>Posted by dietwhisperer:<BR>Sewest, Would you mind to share that documentation tool you mentioned? That would be fantastic! TY. Happy to share but I don't know how to do that from this thread. Can you give me your email address?
Posted by lovey:
Posted by sewest:
Posted by dietwhisperer:
Sewest, Would you mind to share that documentation tool you mentioned? That would be fantastic! TY.
Happy to share but I don't know how to do that from this thread. Can you give me your email address?
Posted by lovey:<BR>Posted by sewest:<BR>Posted by dietwhisperer:<BR>Sewest, Would you mind to share that documentation tool you mentioned? That would be fantastic! TY. Happy to share but I don't know how to do that from this thread. Can you give me your email address?

could you possibly share it with me as well- thank you!

ndkrista@msn.com

could you possibly share it with me as well- thank you! ndkrista@msn.com
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