North Carolina Only: Guidance from Case Mix Reviewers

From North Carolina Newsletter published by Myers & Stauffer:

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Q: We are implementing electronic ADL documentation; what do we need to know in order to meet the Supportive Documentation Guidelines for ADLs?

A: The Supportive Documentation Guidelines for the late loss ADLs require that the keys for self performance and support provided must include all the MDS/ADL key options (key of “7” for self performance is optional) and be equivalent to the intent and definition of the MDS/ADL key. Keep in mind that this applies to either electronic or paper ADL documentation. As part of the review, the RN Reviewer will ask to look at the actual kiosk or computer being used by staff to enter ADL documentation to verify that the language used is equivalent to the intent and definition of the MDS/ADL key. A computer screen that simply shows a picture of an ADL activity, or uses words or phrases (such as “resident does

more than staff”) that are not equivalent to the MDS/ADL key, will result in the ADL values

associated with those keys being unsupported for the review. An electronic system that “converts” these keys to the MDS/ADL key that is printed with the ADLs for the RN reviewer, does not meet the Supportive Documentation Guidelines. Any corrections made to ADL

values must be part of the legal medical record and meet the Medical Record Correction

Policy for MDS Validation Reviews