Progress Note Writing In Ltc/snf's

[QTPitootyFL 0]

I have a question, and I am sorry if this is beaten to death, but my DON stopped me with this today and it made me question myself. Responses can be e-mailed to me as well, lol, cause I will probably see that before I remember to check here... QTPitootyFL@bellsouth.net

 

When exactly is a quarterly note due? Let's say I get my list this week of who I need to put in MDS for. I also get a list of who I will have care plan mtgs for (the people I did MDS for last week). Normally I (and usually the social worker) write the quarterly notes either the morning of the meeting, before the afternoon mtg. This comes from the DON out of the blue after I have been there a little over a year. She says this is a state citation. Is this info documented anywhere? Is there a link someone can send? DON says the note has to be done at the same time I do the assessment/MDS on the computer.

 

Help please,

S----

[StacieO 0]

Hmmm - I've been doing this for about 10 years & this is how I've figured it... I generally, try to do my note around the same time that I do the MDS. I need to have something to reference, where I got my info. (For a RAP for example.) I don't always get them done on the same day, but I do try to have the note done before the care conference, simply because, life happens, I might not be at the conference and I would want the team to have the info. in front of them (our Care Conf. are made up of the interdisp. team, resident, & family). Our social worker and dietary person do their notes the day of the conf. I have NEVER had a surveyor question the date of a note that I have written, or should I say, not yet. Best of luck!

 

Stacie O

[Guest Tinki]

Tag F514 says

 

How often should the professional write in the progress notes? The question surveyors are instructed to ask themselves is: Is there enough recorded documentation for staff to conduct a care program and to revise the program as necessary to respond to the changing status of the resident as a result of interventions? How is the clinical record used in managing the resident's progress in maintaining or improving functional abilities and psychosocial status?

 

Reading this there is not specified time, but I would check your state regulations. Every state is different and I do not know what state you are in. Look on the Department of Human Services website for your state.

 

Secondly, ask your DON where it states this information.

 

Hope this helps,

Karen :-D

[Guest Guest]

ErinE

 

At least in Minnesota, our MDS coordinator uses a form (looks as if developed by our facility) that has: Resident name, Admit date, Assessment reference date, MDS Type, MDS due date, RAP Reviews and/or Quartely note due, and finally Care Plan Date. The form has each of the above set up in columns and is very easy to follow/understand. So, the MDS coordinator sets the whole process up for the interdisciplinary team to follow with specific dates for completion etc. I know the dates are based upon Medicare coverage, type of MDS along with other factors so it varies, meaning, you may have several days inbetween the ARD and due date for MDS or, you may only have 1 day. I don't quite understand the process, I just follow this form to a tee. Sure makes our life easier to know when something is due--no guessing!!

 

Good luck!

[Guest Dee]

In Nebraska we have 7 days to write our note. We have a 7 day look back. Hope this helps-Dee

[Guest Guest_Kathy]

The Federal Regulations.....state that we merely need to do quarterly assessments. Doesn't say a specific time......we used to do the entire facility at once on a quarterly basis and not a peep was heard.......So whatever would work for you! We also have an expression we use frequently when other department folk think that they know what we should do......"Show us the regulation". That usually clears things up right away! We try to state that we would like to see which regulation states that so we can be better people..........

 

Best Wishes with the NURSE!

[gfjones 0]

ErinE

 

At least in Minnesota, our MDS coordinator uses a form (looks as if developed by our facility) that has: Resident name, Admit date, Assessment reference date, MDS Type, MDS due date, RAP Reviews and/or Quartely note due, and finally Care Plan Date. The form has each of the above set up in columns and is very easy to follow/understand. So, the MDS coordinator sets the whole process up for the interdisciplinary team to follow with specific dates for completion etc. I know the dates are based upon Medicare coverage, type of MDS along with other factors so it varies, meaning, you may have several days inbetween the ARD and due date for MDS or, you may only have 1 day. I don't quite understand the process, I just follow this form to a tee. Sure makes our life easier to know when something is due--no guessing!!

 

Good luck!

[gfjones 0]

could you send me a copy of this form? to gjones1946@hotmail.com-Gail Jones ADC

[bigchris 1]

There is usually a difference between the Quarterly Note and the Progress Note. In my mind, the Quarterly note is done when the MDS/CarePlan is done. It is a "check up" on the resident every QTR.

 

In my charts, a Progress note is done whenever I notice a decline/progressive step for the resident in conjunction with the programming that I offer. I don't have a set minimum/limit on when and where I do this ( we have a program that adds it to the charting) so if I am doing/not doing something right. It gives the other team members a heads up on my programs.

 

For instance, I had been given a "project" last week. A resident who wandered constantly out of activities and would not stay focused according to the other staff.

 

I took her on and have been making progress, little by little with the help of therapy. We have been working with her and I have been able to have her in 4 consecutive activities for the duration, both small group and large group. So I put this in her chart. It lets the others know that we do change lives.

 

 

Let me know if I explained it....

 

 

BC

[trixiedg 0]

I have been working with the MDS process for quite a while and did the scheduling in my facility for many years up until recently but still get questions about it from the DON and the MDS coordinator. We also use a homemade form that lets everyone know when things are due. In Mississippi, and I'm sure it's the same everywhere else, each elder has to have an assessment at least every 92 days or when the MDS is submitted to the state it will be late and your facility will be paid at default rate, which is not good. If you have elders receiving rehab, the facility gets paid at a higher rate and if the assessment is late the rate is much, much lower. Annual assessments must be done once a year unless you have a significant change MDS and this will reset your annual date. All of this is a bit confusing I know. If you have an MDS manual it will help to read the section that explains when assessments are due. On our form we have several columns. The first has the elders name, then the date the look back period begins, then the date the MDS starts, which is the day we do our progress notes. The next column has the MDS stop date (the date the MDS is due to go into the computer), then the RAP due date, and finally the care plan due date. All of our MDS's have a 7 day look back period unless it is a medicare 5 day assessment and then it is 5 days. Some portions of the MDS specifies longer look back periods such as the mood section which is 30 days. We write our notes on the day the MDS starts because you're supposed to count anything that occurred during the 7 day period. We have been told if you write it early you may miss something that happened and it may not be coded correctly on the MDS in the end. We have also been told we can write our notes on the day after the MDS starts, but I'm not so sure about this, besides it's hard to break old habits. I think you have 14 days from the assessment reference date (ARD) to complete the RAPs and 21 days from the ARD or day of admit to complete the care plan. We usually try to do ours in less time to make sure we don't go over. Our nurses notes are integrated progress notes which means any discipline can document in them, but I very rarely have time to do this. My quarterly activity progress notes are separate and are placed under the activity tab on the chart. I hope I didn't confuse anyone any more than they already were, but I hope this helps.

[RobinLynn 0]

<span style='color:purple'>I have a question, and I am sorry if this is beaten to death, but my DON stopped me with this today and it made me question myself. Responses can be e-mailed to me as well, lol, cause I will probably see that before I remember to check here... QTPitootyFL@bellsouth.net

 

When exactly is a quarterly note due? Let's say I get my list this week of who I need to put in MDS for. I also get a list of who I will have care plan mtgs for (the people I did MDS for last week). Normally I (and usually the social worker) write the quarterly notes either the morning of the meeting, before the afternoon mtg. This comes from the DON out of the blue after I have been there a little over a year. She says this is a state citation. Is this info documented anywhere? Is there a link someone can send? DON says the note has to be done at the same time I do the assessment/MDS on the computer.

 

Help please,

S----</span>

 

 

Your DON is correct, the quarterly/annual notes should have the date of mds, activities mds part is a week of observation on what the resident has been doing. Example: MDS due date 7-17-07, the MDS should state what the resident did from the 10th to the 17th, as well as the quarterly notes stating all that. Sometimes your MDS due date may change if resident goes to hospital and is re-admitted, then they will get new MDS dates. Make sure you put note in chart of re-admission usually stating res. re-adm. to facility, no change in act. pattern/pref. Will cont. with plan of care. (as long as nothing changed with res.) Remember to put a re-adm. note in chart (1-2 lines), so your dates will not get confusing for you. After re-adm., it starts a new cycle of MDS due dates, although in Florida, they must be in hosp. for 3 nights. HOPE THIS HELPS!! ROBIN

[paw1221 0]

Can anyone give me a run through of the things they include in their annual notes? i just wanted to compare because i wasn't sure if there was a regulation on what information has to be included. any info would be greatly appreciated!

[Jicenogle 0]

Can anyone give me a run through of the things they include in their annual notes? i just wanted to compare because i wasn't sure if there was a regulation on what information has to be included. any info would be greatly appreciated!

 

Resident activity level very independent to 1 to 1 visits only. Resident likes or dislikes. If the resident has participated in any off unit or off campus activites. At the end you should put if youre going to continue with the careplan created the prior year or if some modifications were made.

 

Hope this helps.

[turtle 0]

My activity progress notes include group activities the resident enjoys participating in and how often they attend, independent activities they engage in, family / friend visits, television shows they enjoy, the types of books they like reading, etc. For my residents who are 1:1, I include the types of activities they are most responsive to during 1:1 such as crafts, hand massages, being read to, music, etc. I also try to include things they enjoy talking about and if they receive mail / phone calls. I end my note with an update of their care plan and any changes in their activity preferences.