There is a company that uses intelligent forms on admission that does capture all that information.  The company was IHS (Integrated Health Services), and all their nursing forms were taken from the MDS to ensure coverage of all the information.  The admit assessment includes the vision, hearing, ROM and other info (including dental work!!!) on the form in the MDS language.  Monthly summaries are done in check off format from the quarterly MDS form, and the annuals are done on an annual form straight from the MDS.  It was truly wonderful.  Charting done correctly from the get go.
 
Corey
----- Original Message -----
From: MDSNancy
Sent: Tuesday, March 23, 2004 2:37 PM
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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