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Identify diagnoses: The disease conditions in this section require a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 60 days. ADLs, paresis, or paralysis. NURSING MONITORING.
Steps for Assessment. Review the medical record, including skin care flow sheets or other skin tracking forms. Speak with direct care staff and the treatment nurse to confirm conclusions from the medical record review. Examine the resident and determine whether any skin ulcers/injuries are present.
CMS’s RAI Version 3.0 Manual CH 3: MDS Items [O] October 2023 Page O-1 SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS Intent: The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods.. O01
Planning for Care. Monitor for adverse effects of injected medications. Although antigens and vaccines are not considered to be medications per se, it is important to track when they are given to monitor for localized or systemic reactions.
Intent: The intent of this section is to obtain the reasons for assessment, administrative information, and key demographic information to uniquely identify each resident, potential care needs including access to transportation, and the home in which they reside.
Nursing home staff must use clinical judgment to determine when it is appropriate to reevaluate a resident’s ability to participate in a toileting trial or, if the toileting trial was unsuccessful, the need for a trial of a different toileting program. DEFINITIONS . BLADDER . REHABILITATION/ BLADDER RETRAINING . A behavioral technique that
intain adequate nutrition and hydration. This section covers swallowing disorders, height and weight, weight loss, and nutritional approaches. The assessor should collaborate with the dietitian and dietary staff to ensure that items in this section have.
Mood distress is a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity. It is particularly important to identify signs and symptoms of mood distress among nursing home residents because these signs and symptoms can be treatable.