The process for performing an accurate and comprehensive assessment requires that information about residents be gathered from multiple sources. It is the role of the individual interdisciplinary team members completing the assessment to validate the information obtained from the resident, resident’s family, or other health care team members through observation, interviewing, reviewing lab results, and so forth to ensure accuracy. Similarly, interacting with the resident and direct care staff validates information in the resident’s record.
The following sources of information must be used in completing the MDS. Although not required, the review sequence for the assessment process generally follows the order below:
Review of the resident’s record - Depending on whether or not the assessment is an admission or follow-up assessment, the review could include: preadmission, admission, or transfer notes; current plan of care; recent physician notes or orders; documentation of services currently provided; results of recent diagnostic or other test procedures; monthly nursing summary notes and medical consultations for the previous 60-day period; and a record of medications administered for the prior 30-day period.
Communication with and observation of the resident.
Communication with direct-care staff (e.g., nursing assistants, activity aides) from all shifts.
Communication with licensed professionals (from all disciplines) who have recently observed, evaluated, or treated the resident. Communication can be based on discussion or licensed staff can be asked to document their impressions of the resident.
Communication with the resident’s physician.
Communication with the resident’s family - Not all residents will have family. For some residents, family members may be unavailable or the resident may request that you not contact them. Where the family is not involved, the resident may request that someone else who is very close to him/her be contacted.
REVIEW OF THE RESIDENT’S RECORD
The resident’s record provides a starting point in the assessment process to review information about the resident in written staff notes across all shifts over multiple days. Starting with the resident’s record, however, does not indicate that it is the most critical source of information, but only a convenient source.
At admission, record review includes an examination of notes written in the first 2 weeks (assuming the full 14-day period is used to complete the assessment), documentation that came with the resident at admission, facility intake forms (e.g., social service notes), and any preadmission test results including copies of the MDS and RAPs from another nursing facility if the resident was transferred. Obviously, transcribing the previous facility’s MDS is inappropriate.
Subsequent reassessments should focus on recorded information from earlier MDS assessments and Quarterly assessments, written information from the previous 3-month period, and notes made during the prior 30-day period.
The following are important considerations when reviewing the resident’s record:
Review the information documented in the record, keeping in mind the required MDS definitions. Make sure that assumptions based on the record are compatible with MDS definitions (e.g., resident self-performance is evaluated with appliances if used, such as locomotion with a walker; similarly, according to the MDS, a resident, who stays “dry” with a catheter may be considered continent).
Make sure that the information taken from the record covers the same observation period as that specified by the MDS items. The MDS refers to specific time frames for each item; for example ADL status is based on resident performance over a 7-day period. To ensure uniformity, the MDS has an Assessment Reference Date (A3a) that establishes a common reference end-point for all items. Consequently, it is necessary to pay careful attention to the notes regarding time frames for each section of the MDS and also to the Item-by-Item instructions in Chapter 3.
Be aware of discrepancies and view the record information as preliminary only. Clarify and validate all such information during the assessment process. Be alert to information in the record that is not consistent with verbal information or physical assessment findings. Discuss discrepancies with other interdisciplinary team members (e.g., nurses, social workers, therapists). The extent to which the record can be relied upon for information will depend on the comprehensiveness of the record system. Note what information the record usually contains (e.g., current service notes, care plans, flow sheets, medication sheets), where different types of information are maintained in the clinical record, and more importantly, what information is missing.
Where information in the record is sufficiently detailed and conforms to MDS descriptions and time periods, complete the MDS items. A few MDS items can be completed in full from information found in the record. Comprehensive and accurate assessment of most items, however, requires information from other sources (i.e., the resident, the resident’s family, and facility staff). Where information is incomplete or contradictory, make a note of the issues in question. This note can help plan contacts with the resident, facility staff and resident’s family. There is no requirement that such a note be maintained as part of the resident’s permanent record; it is a suggested work tool only.
As you observe, talk with, and discuss the resident with other staff members, verify the accuracy of what you learned from reviewing the record.
COMMUNICATION WITH AND OBSERVATION OF THE RESIDENT
The resident is a primary source of information and may be the only source of information for many items (e.g., customary routine, activity preferences, vision, hearing, identification with past roles, and, in some instances, problem conditions). Many MDS items will not be documented elsewhere in the clinical record, and the completed MDS may ultimately be the single source of documentation about these issues.
Become familiar with the MDS items to make communication and observation of the resident an ongoing everyday activity in the facility. For example, an RN can observe and interact with a resident when medications are given, during meals, or when the resident comes to ask a question. Interaction with the resident may be a crucial factor in confirming staff judgments of resident problems. Weigh what the resident says, and what is observed about the resident against other information obtained from the resident record and facility staff.
To be most efficient, organize a framework for how to interview and observe the resident. Allow flexibility to accommodate the resident. Carefully listen and observe the resident to get guidance as to how to pursue the necessary information gathering. Try to interact with the resident, even if the resident may have difficulty responding. The degree and character of the difficulty in responding, as well as nonverbal responses (e.g., fearfulness) provide important information. Sensitive staff judgment is necessary in gathering information. For further information on “Interviewing Techniques” see Appendix D.
It is important to observe, interview and physically assess the resident, and to interview staff. In addition, the MDS was designed to consider information obtained from family members, although it is not necessary that every discussion with them be face-to-face. Assessors should capture information that is based on what actually happened during the observation period, not what usually happens. Problems may be missed when the resident’s actual status over the entire observation period is not considered.
Any person completing any MDS section is required to follow the Item-by-Item guidelines in Chapter 3 of this manual that specify sources of information necessary for accurate coding. The process of information gathering should include direct observation of the resident; communication with the resident’s direct caregivers across all shifts; review of relevant information in the resident’s clinical record; and if possible, consultation with family members who have direct knowledge of the resident’s behavior in the observation period. If the person completing the MDS did not personally observe for example a behavior, but others report that it occurred, the behavior must be considered as having occurred when completing the MDS form. In addition, the resident’s clinical record should support their status as reported on the MDS.
COMMUNICATION WITH DIRECT CARE STAFF
Direct care staff (e.g., nursing assistants and activity aides) having daily, intimate contact with residents is often the most reliable source of information about the resident. Direct care staff talk with and listen to the residents. They observe and assist the resident’s performance of ADLs and involvement in activities. They observe the resident’s physical, cognitive and psychosocial status daily during all shifts, seven days a week. Key considerations when communicating with direct care staff are:
Be sure to speak with a person who has first-hand knowledge of the resident. Plan for sufficient time to talk with direct care staff person(s).
Start by asking about the resident’s performance on ADLs and activities. What can the resident do without assistance? What do staff members do for the resident? What might the resident be able to do that he or she is not doing now? Continue by asking about communication and memory skills, body control, activity preferences, and the presence of mood or other behavioral symptoms.
Talk with direct care staff across all shifts, if possible. The information from other shifts may be obtained in other ways as well (e.g., from change-of-shift reports if direct care staff comments are included).
COMMUNICATION WITH LICENSED PROFESSIONALS
Licensed practical nurses (LPNs), RNs, social workers, activities professionals, occupational therapists, physical therapists, speech therapists, pharmacists, dietitians, and other professionals who have observed, evaluated, or treated the resident should be interviewed about their knowledge of resident capabilities, performance patterns, and problems. Their special expertise will enhance the accuracy and comprehensiveness of the resident assessment.
COMMUNICATION WITH THE RESIDENT’S PHYSICIAN
The physician’s role is central to the overall management and outcome of resident care. The MDS assessment process should include a review of the physician’s examination of the resident, plan of care, hospital discharge plan, goals of care, and medication and treatment orders. At the Quarterly assessments and Annual assessments, review the most recent physician orders and notes. Also, review the MDS with the resident’s attending physician to share and validate pertinent information. If there is difficulty obtaining information or input for the assessment from the attending physician (or transferring institution), the facility’s medical director should be asked to intervene.
COMMUNICATION WITH THE RESIDENT’S FAMILY
The resident’s family (or person closest to the resident) can be a valuable source of information about the resident’s health history, history of strengths and problems in various functional areas, and customary routine prior to the first nursing facility admission. This information is particularly necessary when the resident is cognitively impaired or has a great deal of difficulty communicating. Using this source obviously depends on the presence of family members, their willingness to participate, and the resident’s preferences. Facilities need to respect the cognitively intact resident’s right to privacy, and should have permission from the individual for staff to ask questions of family members. In most instances, family will not be the sole source of information but will supplement information from other sources. The assessment process provides an excellent opportunity for caregivers to develop trusting, working relationships with the resident and family.