The Minimum Data Set provides details in nursing home records
In a previous blog post, we met Mr. Hansen and learned some of the important details of his life at the nursing home. After Mr. Hansen’s death, his family believed the nursing home failed to provide care for Mr. Hansen, leading to his accident and subsequent death. The Hansen family engaged the services of an attorney to seek justice for Mr. Hansen. The search for justice for Mr. Hansen began, as it does for many nursing home residents, in the details of a lengthy medical record.
The MDS (Minimum Data Set) is a common nursing home resident assessment record. The MDS assessment is a compilation of assessments performed by different departments in the nursing facility over a specified period of time, usually seven days. The MDS assessment is required not only once, but at prescribed periods throughout a resident’s stay in the facility. The assessment data is then forwarded electronically to CMS (The Centers for Medicare and Medicaid Services) to determine the facility’s reimbursement for the resident’s care.
The MDS sections are identified by alphabet and title. We’ll resume Mr. Hansen’s MDS with Section G.
Section G, Functional Status, details Mr. Hansen’s independence or need for assistance in his activities of daily living (ADLs).
ADLs are the things we do every day, without much thought about them, if we’re healthy. Activities such as bed mobility (moving about in bed), ambulation, dress, performance of hygiene, bathing, and toileting activities. Each ADL is given two scores. One score is for performance (independent to totally dependent) and the second score is for how many staff were required to assist the resident in performing that activity (range from none to more than two). Section G also scores the resident’s balance in walking, his range of motion, and which type of mobility device the resident used for mobility.
Section GG, Functional Abilities and Goals, is an assessment of ADLs and ambulation similar to Section G. Section GG information is completed only on the resident’s initial admission during days 1 through 3.
Section H, Bowel and Bladder, documents whether the resident had appliances such as an indwelling catheter or ostomy (for bladder or bowel output and collection). Section H also records whether the resident was on a toileting program, and the level of bowel and bladder continence.
Section I, Active Diagnoses, provides a list of diagnoses for the assessor to check-off and blank space for diagnoses not listed to be entered.
Section J, Health Conditions, records information about the resident’s pain and pain management by the facility. Thirteen questions relating to pain document whether the resident has received scheduled or as needed pain medication in the five days prior to the assessment. The resident is interviewed regarding the presence of pain, and the frequency, intensity, and effect of pain on function. If the resident is unable to respond, the staff records their assessment of the resident’s indicators of pain or possible pain (such as verbal or facial expressions, or guarding behavior).
Other health conditions including shortness of breath, current tobacco use, and other conditions are documented in Section J. The resident’s fall history is recorded in Section J, including documentation of the number of falls, and whether there was no injury, minor injury and/or major injury associated with the resident’s falls.
Section K, Swallowing/Nutrition Status, records signs and symptoms of a possible swallowing disorder, with a checklist to describe the specific symptoms or behavior. The resident’s height, weight (and loss or gain), nutritional approach and percentage of intake by artificial route (parenteral or tube feeding) are also recorded in Section K.
Section L, Oral/Dental Status, documents the resident’s dental status. Section L details the resident’s dentition and the oral cavity in assessments including whether dentures fit or were broken, mouth lesions were present, and if there was mouth or facial pain or difficulty in chewing.
Section M, Skin Conditions, documents pressure ulcer characteristics including quantity, location, stage, and dimensions. Assessment of venous and arterial ulcers, and skin and ulcer treatments is also in found in Section M.
Section N, Medications, documents the number of days (within a specified timeframe) the resident received injections, insulin, and medications from a list of the specified classes of medications.
Section O, Special Treatments, Procedures, and Programs, records treatments and care the resident received prior to admission to the facility and since admission to the facility. These include treatments for cancer, respiratory conditions, dialysis, and intravenous medications. Documentation of the resident’s influenza and pneumococcal vaccine history are recorded in Section O. The length of time in minutes the resident received speech, occupational, physical and respiratory therapies in the assessment timeframe. The number of days the resident received restorative nursing programs, and the number of days the physician visited within the MDS assessment timeframe can be found in Section O.
Section P, Physical Restraints, notes the type of restraint, frequency used, and whether the restraint was used in bed and/or while the resident was up in a chair.
Section Q, Participation in Assessment and Goal Setting, refers to the resident’s participation in the assessment, and the resident’s expectation of remaining at the facility or being discharged. If the resident is unable to participate in this section, the assessment form provides coding to record who participated on the resident’s behalf.
The final three sections of the MDS are focused on the administration of the MDS assessment information.
Section V, Care Area Assessment Summary lists twenty care areas that might be triggered by the MDS assessments. The triggers note which areas the resident has need for his plan of care to be initiated or updated.
Section X, Correction Request, is utilized in the event that an error was entered into the assessment but not discovered until after the assessment was sent to CMS.
Section Z, Assessment Administration, provides documentation for billing codes for Medicare, Medicaid and insurance. The final page is the signature page for the healthcare providers who performed and documented any of the assessments in the MDS. The section also notes which sections of the MDS were completed by each individual. The signature of the Registered Nurse who coordinated and verified the completion of the documentation is also in Section Z.
As you can see, the MDS documents a variety of assessments during a known time period for nursing home residents. Because an MDS assessment is a record of a “snapshot” of time, it can be helpful to review more than one MDS. This would provide the reviewer a better picture of changes that may have occurred in a resident’s clinical status. For example, the resident may have had changes in cognition, ability to perform ADLs or ambulate. Reviewing the changes in the MDS, might then direct the reviewer to a specific period of time in the other parts of the medical record for more details.
If you have clients who, like Mr. Hansen’s family, want to know the truth about their loved one’s stay at a nursing home, and you have voluminous records to review, call me. I can help.
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