We have nursing flow records that cover those mentioned areas qshift/qday,
it is also on our nursing admission assessment, but we are a short term
hospital based unit so my information is always documented in an assessment
window and that is not going to help you, but, what I have seen in the past
is that you try to schedule your monthly summaries (if done) to coincide
with the MDS due date and that could be your documentation.
 

Tammy Gola BSN, RN, CRNAC 
Wilkes-Barre General Hospital 
Transitional Care Unit 
575 North River Street 
Wilkes-Barre, PA. 187641-0001 
570-552-5417 
[EMAIL PROTECTED] 

 

-----Original Message-----
From: MDSNancy [mailto:[EMAIL PROTECTED]
Sent: Tuesday, March 23, 2004 2:37 PM
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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