Trepidation, fear and confusion have all been experienced by minimum data set (MDS) coordinators and staff alike at various long-term post-acute care (LTPAC) facilities regarding selecting and/or having to code diagnosis for residents—especially upon admission. Some common questions include: “What do I choose?” “How do I know if it is the correct primary or admitting diagnosis?” “I’m not a coder—how do I know what diagnosis to choose?”
Utilization of Electronic Health Record (EHR) has opened the door for many persons/facilities/organizations to become active in customizing and/or adding items to their database wherever possible. The ability to add facility or organizational specifics has enabled uniformity and consistency with the building of templates/pick-list(s) and libraries. It can be either the time saving tool everyone loves or a problematic add-on that can have both monetarily or regulatory implications.
Repeatedly, I hear MDS Nurses stating that it’s “not their job” to oversee or manage the diagnosis. Honestly, as a previous MDS Nurse, I cannot believe there is even a question as to who is responsible. So, I ask them: Who signs Section I of the Minimum Data Set (MDS)?
Topics: Clinical Consulting
As Ohio LTPAC facilities raced to complete the PELI (Preferences for Everyday Living Inventory) as directed by the Ohio Department of Medicaid for each in-house resident by the 12/31/15 deadline in order to earn one Quality Indicator point, it left many with the question, “What’s the next step?”
Topics: Financial Consulting