ASSESSMENTS:

SOMETIMES LESS IS MORE

By Karen Lilyquist
Fall 2006

The saying exists: If it wasn't documented, it wasn't done. Undeniably, documentation reflects a resident's status, the staff's interventions, and changes to either. However, too much documentation can lead to discrepancies. Conflicting data can cause as much harm as not enough data (or more) in the survey process.

Data must be accurate and consistent, but one does not need numerous forms to obtain it. The more forms in the chart; the more chance for error. For example, documenting weights in the MAR, the electronic record and the vital sign flow sheet increases the risk for contradictions, missed weight changes and delayed interventions. It also increases the risk of questions during the survey process.

Another example is that of pressure ulcer documentation. A facility must conduct a comprehensive assessment of each resident's needs (MN Rule 4658.0400 Subpart 1). Specific to pressure ulcers: a facility must conduct a comprehensive assessment of a resident's risk factors and conditions related to the development of pressure ulcers (F 272). Based on the comprehensive assessment, a resident having pressure sores must receive necessary treatment and services to promote healing, prevent infection and prevent new sores from developing (F 314).

Recording wound size, characteristics and interventions in one location allows staff to easily spot missed entries, inaccuracies / inconsistencies or delayed healing earlier than if the MDS nurse were to discover the items upon quarterly review. Missed assessments must be completed. Inaccuracies must be corrected. And, delayed wound healing requires attention (i.e., informing the MD/NP, family, Therapy and Dietitian; obtaining different treatment orders; ensuring that appropriate turning, repositioning, and other pressure relief interventions are appropriate, etc.) to promote wound healing. Untimely intervention leads to negligent care and questions by the surveyors. Using one form minimizes this risk.

Another issue arises when different departments complete their own forms as separate parts of the whole assessment process. One example is when social services assesses mood and behavior and documents the data on their departmental form, rather than documenting the data in an interdisciplinary note or on the comprehensive intake form. Another example is when recreational therapy notes a resident's need for large print materials on their assessment rather than alerting the interdisciplinary team by adding it to the care plan. If individual departments are not seeing the big picture, things get missed. Surveyors will assume that employees, who cannot assess the patient comprehensively, can't develop a care plan to meet a resident's holistic needs.

Karen Lilyquist, PhD, RN, RD, LD, is a Nurse Consultant for Pathway Health Services.