Monday, September 13, 2010

Interview Documentation

Q:  Where do I document all my results from the interviews I complete?

A:  The MDS 3.0 is now a source document.  If the resident is interviewable, the answers that they give are directly documented on the MDS tool for each interview completed.  The scores or answers may result in a CAT (Care Area Trigger) on specific types of MDS’s (OBRA Admission assessment, Significant Change in Status assessment, Annual Assessment or Significant Correction of a prior Comprehensive assessment) and a  CAA (Care Area Assessment) can  be completed to determine the cause of the triggered area. Also, your resident’s clinical record is a source document and you can site the location of information that may support the triggered area. 

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