How to Accurately Complete the MDS 3.0

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Accurately capturing Activities of Daily Living (ADLs) data when completing MDS 3.0 assessments is important for reimbursement. It is also essential to have an accurately completed MDS 3.0 assessment so that an individualized plan of care can be developed and implemented. Let's look at accurately completing MDS 3.0 Assessments.

A truly comprehensive care plan acknowledges all of the resident-specific problems, strengths, and needs—it paints a picture of who the resident is.

The Importance of Accuracy

The importance of the accuracy of the MDS 3.0 document needs to extend beyond establishing reimbursement. This assessment tool gives a nursing home a great deal of information for developing a plan of care for that resident. The MDS process currently incorporates resident interviews to obtain information on a resident’s mental status, mood state, preferences for customary routine and activities, and pain—all significant factors that affect Quality of Life and Quality of Care.

For example, the interview for preferences can be a rich source of information to individualize a plan of care based on resident choice and likes/dislikes. This interview can extend to family members or a significant other if the resident is unable to be interviewed, providing more thorough data.

This interview should provide pertinent information regarding a person's prior life and expectations of how he or she would like his life to be when in the nursing home. With this type of information, the nursing home staff should find it difficult to ignore the individuality of the resident, resulting in a good quality of life for a happy, satisfied resident.

A different perspective on the resident is obtained from interviewing the clinical staff responsible for the resident’s care, leisure needs, etc. These interviews paint a true picture of the resident that cannot be captured if you only speak with daytime caregivers.

Quality of Life and Quality of Care concerns are highlighted when the MDS is accurately completed, and the information from these assessments is essential in developing a plan of care. When a nursing home is surveyed, the data from MDS assessments is utilized in determining which care areas should be assessed by the State survey team.

An inaccurate MDS assessment can result in inaccurate Quality Measure information. Clinical staff members responsible for completing the MDS assessment need to be well-trained and knowledgeable in accurate completion of this assessment, as well as in identification of potentially problematic areas that might not trigger on an MDS but should be recognized when developing an individualized plan of care.

All staff involved in the completion of MDS assessments and the associated development of an individualized, comprehensive care plan need to understand that the information found in the MDS is a key component in the fabric of a nursing home resident’s life.

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