MDS Alert

Get your documentation in a row for the new RUG system.

If you don't want to be held captive by irate government auditors demanding to know why you captured hospital services inappropriately on the MDS, revisit your admission documentation systems.

Case in point: United Helpers Nursing Home has an admissions coordinator who goes to the hospitals to see patients before they are admitted to the SNF and works with the discharge planners to obtain the needed information, says Norma Jean LaPoint, RN, MDS coordinator for the Ogensburg, NY facility. The MDS team also receives a packet of information and documentation from the hospitals for new admissions. The MDS team knows to look for IV medications or fluids for residents with diagnoses of dehydration, urosepsis or UTI or pneumonia, as examples.
 
Strategy: Before coding the MDS, LaPoint checks the resident's hospital medication administration record (MAR) for the date of the last dose of medication--and the IV flow sheets to see when IV fluids were discontinued. Confirming that a resident received suctioning during the hospital stay can be more difficult, however, LaPoint notes. To do that, the facility has a HIPAA-compliant computerized program that provides access to the transferring hospital's  electronic medical record system.