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Nursing | Other Nursing


Rachelle Larsen


Minimum Data Set (MDS) is used in long-term care facilities to document resident’s information and assessments and to determine the resident’s eligibility to receive Medicare or Medicaid insurance coverage for treatment expenses while in the LTC facility. When reviewing the MDS, the facility identified inaccurate documentation of the resident’s functional mobility ambulating on the unit. This quality improvement project was undertaken to improve assessments, resident interventions, and documentation regarding functional mobility. Following literature review and chart audits, an educational intervention was implemented for nursing assistants to promote understanding of the MDS coding system when charting functional mobility on the unit. The educational intervention included information on coding for the level of staff assistance and accurate charting of assistance levels. Following the education intervention data was again collected through chart review on MDS coding to determine effectiveness of the intervention. The goal of this project was to create more accurate MDS documentation and ultimately improve resident independence while ambulating on the unit in this long-term care facility.

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