Practice Consideration
Minimum Data Set (MDS) and Care Plan (CP) Flow List - Bishops Glen
Following is a description of the required documentation for the MDS and the Care Plan for the first year for a long term care resident in this particular facility.
| Minimum Data Set (MDS) and Care Area Assessment (CAA) | Care Plan (CP) and Nutrition Assessment Reviews | |
|---|---|---|
| Day 1 | Admission | Day 1 & 2: Interim Baseline Care Plan initiated |
| Day 14 | Initial MDS Section K, Swallowing/Nutritional Status, Care Area Assessment 12, Nutritional Status |
Initial Dietitian Nutrition Assessment Monthly High Risk Tracking Form |
|
Baseline Care Plan completed Care Planning Meeting* |
||
| Day 30 | MDS Section K (only if signficant change) | Update Baseline Care Plan or Nutrition Care Plan as needed, Monthly High Risk Tracking Form |
| Day 60 | MDS Section K (only if significant change) | Update Baseline Care Plan or Nutrition Care Plan as needed, Monthly High Risk Tracking Form |
| Day 90 (3 Mo) | Quarterly MDS Section K (and/or L), CAA . evaluate for Significant Change in Status* | Dietitian Re-Assessment , Monthly High Risk Tracking Form, and update nutrition care plan as needed |
| 4 Mo | Evaluate for Significant Change in Status* | Monthly High Risk Tracking Form |
| 5 Mo | Evaluate for Significant Change in Status* | Monthly High Risk Tracking Form |
| 6 Mo | Quarterly MDS Section K (and/or L), CAA . evaluate for Significant Change in Status* | Dietitian Re-Assessment , Monthly High Risk Tracking Form, and update nutrition care plan as needed |
| 7 Mo | Evaluate for Significant Change in Status* | Monthly High Risk Tracking Form |
| 8 Mo | Evaluate for Significant Change in Status* | Monthly High Risk Tracking Form |
| 9 Mo | Quarterly MDS Section K (and/or L), CAA . evaluate for Significant Change in Status* | Dietitian Re-Assessment , Monthly High Risk Tracking Form, and update nutrition care plan as needed |
| 10 Mo | Evaluate for Significant Change in Status* | Monthly High Risk Tracking Form |
| 11 Mo | Evaluate for Significant Change in Status* | Monthly High Risk Tracking Form |
| 12 Mo | Quarterly MDS Section K (and/or L), CAA . evaluate for Significant Change in Status* | Dietitian Re-Assessment , Monthly High Risk Tracking Form, and update nutrition care plan as needed |
| Continues in same frequency | ||
*Any time a Significant Change in Status is noted a CAA is completed, MDS Section as appropriate, modifications to nutrition care plan as needed and Dietitian participation in Care Planning Meeting (NOTE: At this facility the CDM participates in all Care Planning Meetings)
Updated October 13, 2020