As a nurse leader, what can I do to help create a solid process for nursing documentation under PDPM?
Begin with what correct and complete documentation looks like. Facilities often have nurses use checklists to mark their assessment findings. While a checklist may help capture a condition recorded on the MDS, it may not capture all aspects of an assessment or detail the care that was delivered.
In these final months before PDPM, provide monthly education on documentation expectations. Educate your team on an accurate and complete head-to-toe assessment, which provides critical baseline information upon admission and throughout a resident’s stay regarding physical, mental and emotional status. The goal is to discover and document abnormal findings that signal an underlying disease or change in condition that may warrant further evaluation and intervention.
Provide advanced education on specific conditions, for example, pressure ulcers/injuries, that require very detailed documentation — in this example, staging, measurements, wound characteristics (wound bed/edges, drainage, pain, infection), and pressure-relieving devices being used. By recording this information, your team can track a resident’s progress.
For the remaining documentation education, cover high-acuity conditions and conditions or services that impact reimbursement. These include Tracheostomy care, IV feedings, IV medications, and infection isolation.
Educate on items that, when under-documented, can’t support MDS coding, such as signs and symptoms of a possible swallowing disorder or of a chronic condition such as lung disease.
Conduct monthly chart audits, not only to ensure the education is being carried over into practice but also to identify educational opportunities.
