Re: RNAC's, do you do mds documentation?

[carol maher]

When I am doing the physical assessments for an MDS, I document the findings during the observation window myself.  On some of my units, I have trained the regular nurses to do the physical exams for the MDS (vision, hearing, communication, skin, etc) and then have them document their findings.  It has worked well.  Spending some time teaching, giving them tools, pays off in the long run.  When new nurses are added, the education must be repeated, but again, it saves time in the long run.


-----Original Message-----
From: MDSNancy <[EMAIL PROTECTED]>
Sent: Mar 23, 2004 11:37 AM
To: [EMAIL PROTECTED]
Subject: RNAC's, do you do mds documentation?

I have a question for all the rnac's out there.  This has come up before.  I have asked a question of this type before.  I am not interested in the disciplinary process for nurses who are not documenting what needs to be documented during an assessment week.  My problem is new nurses, not totally familiar with the process (I am inservicing), agency nurses who don't really care (sorry to all the agency nurses out there), and nurses who are resigning.  This is leaving a big hole in the documentation (particularly vision, hearing, memory, decision making, etc.....).  This is my question.  

1. If the information is just not there, can I use "dashes" on the mds?

Even for PPS mds's? 

2.  How many rnac's are doing their "own" assessments during the assessment period?   And I did see a comment about this as a potential problem for surveyor's that the only documentation is from the rnac.  I don't mean fall assessments, or braden skin assessments. I mean documenting on vision, hearing, memory, and things like that.   

I guess I'm frustrated today!   I just heard another nurse is resigning today,  she is the only nurse who consistently documented what is needed on that unit!  

So, any thoughts?

Thanks, Nancy

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