MDS Alert

Simple tips help back up your coding.

Knowing a resident received a certain level of ADL help in the hospital before admission to the SNF is one thing, but legitimately coding it in Section G is another.

The RAI compliance bottom line: To count hospital ADLs, you should have some form of documentation --" for example, you might find it on the transfer form where the hospital indicates the level of assistance a patient required, says Joan Brundick, RN, Missouri state RAI coordinator.

Make sure, however, that whoever documented the ADL help used the same terminology as the MDS for coding purposes, advises Marilyn Mines, RN, RAC-CT, BC, manager of clinical services for FR&R Healthcare Consulting in Deerfield, Ill.

Example: If the hospital documentation stated the patient needed two people to lift her out of bed, that would meet the definition of weight bearing, Mines adds. But if hospital staff documented that the patient needed assistance or minimum assistance, clarify what that means.

One option: The SNF's preadmission nurse could interview hospital staff to determine the resident's specific level of ADL self-performance and support, says Mines. The nurse could then document that information in the resident's clinical record, which would provide supportive documentation for coding Section G1. "The RAI manual says you can use staff interviews for coding any section of the MDS," Mines says.