The Centers for Medicare and Medicaid Services (CMS) is sending nationwide its 2014 pilot survey that examined Minimum Data Set 3.0 (MDS 3.0) coding practices and their relationship to nursing home resident care.
The pilot results revealed significant discrepancies between the MDS 3.0 and a resident’s medical record in four of seven clinical conditions reviewed.
Particularly concerning is a 15.4% disagreement in late loss ADL status, meaning one in every seven cases is being coded differently that would be expected, based on a resident’s medical records.
According to Renee Kinder, writing for McKnights, one way to reduce disagreements between technology and written records is to “improve understanding between the language MDS uses to define levels of function and impairment in comparison to how rehab teams and nursing define these areas.”
Essentially, caregivers need to agree, not only on their assessment of a resident’s condition, but also on the way it is technologically coded, and that takes consistent practice and communication among departments. Kinder encourages the “use of simplified instructions, appropriate vocal intensity from caregivers, and use of closed versus open-ended questions when communicating during tasks” to help caregivers use MDS to paint a clear picture of individualized needs.
Source: McKnights: Evaluating Extensive vs. Moderate Assist
