MDS Alert

Here's how to ensure you have the right info and documentation.

If you're looking for an accurate, easy way to assess and document a resident's decision-making ability at B4, get the team on the case.

"The best way to assess and code [B4] is for the person coding the MDS to be sure to collect information about this from everyone in the facility who comes in contact with the resident," says Rena Shephard, RN, MHA, FACDONA, president of RRS Healthcare Consulting in San Diego. You might ask staff how the resident has made choices during the lookback, she says. "How has he done, for example, in selecting clothing items or how did he do in knowing when to go to meals or activities?--that sort of thing. Then the person coding the MDS can use that information to make a coding decision."

Tip: Question coding a resident as a "2" just because the staff thinks the resident isn't making the "right" decisions, advises Marilyn Mines, RN, BC, director of clinical services for FR&R Healthcare Services in Deerfield, IL.

Example: Mrs. R always wears sleeveless dresses and blouses. But during the winter season, staff believes she should wear long sleeves and perhaps a sweater. So "the staff cues the resident to change her clothing decision, but she insists she's always warm and will wear a sweater when needed," relays Mines. Since Mrs. R is making the decisions, the MDS team shouldn't code her as a "2" at B4, Mines advises.

Nail Down the Documentation

In order to support the coding decision, the MDS nurse can write an interdisciplinary progress note in the MDS section of the chart to summarize the team's comments about the resident's decision-making during the lookback, suggests Shephard.

Also teach the interdisciplinary staff members to document a resident's decision-making as they perform their assessments, suggests Nancy Augustine, RN, MSN, a consultant with LTCQ Inc. For example, "when the nurse passes medications and asks the resident if he has any pain--and the resident says yes, and I've tried this and this to relieve it--that's evidence of decision-making."

Documentation tip: If social services only documents a resident's cognitive status quarterly, "you'll need supportive documentation about how the resident performed cognitively during the seven-day lookback," reminds Roberta Reed, MSN, RN, clinical care manager at Legacy Health Services in Ohio.