RAI-MDS 2.0 Nutritional Care Resource Guide April 2011 - CCIM

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CHAPTER 2: RAI-MDS 2.0 AssessmentCHAPTER 2: RAI-MDS 2.0 Assessment....................................................1Selected Coding Sections of RAI-MDS 2.0 ..............................................2Overview of Assessment Timelines ......................................................10RAI-MDS 2.0 Nutrition Assessment Process for:...................................16Admission ...........................................................................................................................................................16RAI-MDS 2.0 Nutrition Quarterly, Significant Change or Annual Assessment Process......................................19Scheduler for Part Time Team Member.................................................21Preparing to Code Checklist..................................................................22Coding Software Orientation Checklist.................................................23Recommended Tools (Optional) ............................................................24Admission Nutrition Assessment Worksheet (optional) For Beginning RAI-MDS 2.0 User ................................24Admission Nutrition Assessment Worksheet (optional) For Experienced RAI-MDS 2.0 User ............................28Nutrition/Hydration Risk Identification Tool - Optional ........................................................................................32For Information: 416.327.7625 1ltchrai@ontario.ca
Selected Coding Sections of RAI-MDS 2.0INTRODUCTION The most common RAI-MDS 2.0 section that the nutrition care team is responsible for is all or part of Section K:Oral/Nutritional StatusOther sections that the nutrition care team may be responsible for and/or contribute to are:- J1d: Insufficient Fluid- M5d: Nutrition or Hydration to Manage Skin ProblemsIndividual home’s policy will determine who completes each section of the RAI-MDS 2.0 assessment. It isimportant that the registered dietitian and nutrition manager are familiar with all nutrition care related codingregardless of whether they complete the coding or notThe nutrition care team is responsible for verifying coding accuracy before completing RAPs and care planningGETTING READY FOR CODING It is important to know the following for each RAI-MDS 2.0 assessment item:- coding intent and the assessment period (e.g. last 7 days, 14 days, 30 days)- coding choices and definition- approach/process for gathering the coding informationK1: ORAL PROBLEMSINTENT:To record any oral problems present in the last 7 days.CODING CHOICES AND DEFINITIONS:a. Chewing problem: Inability to chew food easily and without pain or difficulties, regardless of cause (e.g.resident uses ill-fitting dentures, or has a neurologically impaired chewing mechanism, or a painful tooth).b. Swallowing problem (Dysphagia): Clinical manifestations include frequent choking and coughing wheneating or drinking, holding food in mouth for prolonged periods of time, or excessive drooling.c. Mouth pain: Any pain or discomfort associated with any part of the mouth, regardless of cause.d. None of the abovePROCESS: Ask the resident/family about difficulties in the areas of chewing, swallowing and mouth pain Observe the resident during meals Inspect the mouth for abnormalities that could contribute to the above problemsREMEMBER:Continue to code chewing and swallowing problems even when compensatory strategies have been successfullyintroduced, but the resident remains unable to chew all types of foods and liquidsFor Information: 416.327.7625 2ltchrai@ontario.ca2
Page 1 and 2: RAI-MDS 2.0 Nutritional Care Resour
Page 3 and 4: Table of Contents1. Chapter 1: RAI-
Page 5 and 6: Glossary of TermsADLAlgorithmAverag
Page 7 and 8: RAI-MDS 2.0 Target population:Frail
Page 9 and 10: SECTION F: PSYCHOSOCIAL WELL-BEINGI
Page 11 and 12: SECTION P: SPECIAL TREATMENTS AND P
Page 13 and 14: SECTION V - RESIDENT ASSESSMENT PRO
Page 15 and 16: OUTCOME SCALES OR MEASURES• 10 ou
Page 17: Getting Started ChecklistCompletion
Page 21 and 22: WEIGHT CHANGE CALCULATION EXAMPLE:C
Page 23 and 24: EXAMPLE:Step 1: Calculate Total Cal
Page 25 and 26: Examples include wheat-free diet to
Page 27 and 28: Overview of Assessment TimelinesOBS
Page 29 and 30: 2. QUARTERLY ASSESSMENT TIMELINEThe
Page 31 and 32: TIMELINE FOR SIGNIFICANT CHANGE IN
Page 33 and 34: RAI-MDS 2.0 Nutrition Assessment Pr
Page 35 and 36: Day 0 First Day of New Admission On
Page 37 and 38: RAI-MDS 2.0 Nutrition Quarterly, Si
Page 39 and 40: Preparing to Code ChecklistThe foll
Page 41 and 42: Recommended Tools (Optional)Admissi
Page 43 and 44: Sensory Deficit Affecting Nutrition
Page 45 and 46: Admission Nutrition Assessment Work
Page 47 and 48: Essential Nutritional Assessment Ar
Page 49 and 50: Nutrition/Hydration Risk Identifica
Page 51 and 52: Assessing Nutrition / Hydration Ris
Page 53 and 54: CHAPTER 3: Resident Assessment Prot
Page 55 and 56: TRIGGERED RAPS IN THE RAI-MDS 2.0 R
Page 57 and 58: TRIGGERED RAP OR NON-TRIGGERED CLIN
Page 59 and 60: What have you read to support evide
Page 61 and 62: NO EXISTING RAP TRIGGEREDIf existin
Page 63 and 64: RAP IMPLEMENTATION STRATEGIES Compl
Page 65 and 66: NEW ADMISSION RAP AND CARE PLAN TIM
Page 67 and 68: M axim um 7 days M aximum 7 days Ma
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RAPS and Care Planning Software Ori
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The College of Dietitians of Ontari
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8 Documentation by the dietitian in
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17.10 Draws relevant conclusions fr
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RAPProcessLeaves25% ormore foodunea
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RAP Process Step 1Type of RAPLeaves
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Dietitian ReferralDietitian Referra
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13. Dental Care14. Pressure UlcersD
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New triggered RAPs affecting nutrit
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Criteria to Review4. Evidence of RA
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OverviewOVERVIEW• Getting started
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MoodWorsened mood - symptoms of dep
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15. Prevalence of depression withou
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• E1l - Sad, pained worried facia
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AGGRESSIVE BEHAVIOUR SCALE (ABS)•
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• Hemiplegia, pneumonia, septicem
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Preparing for RAI-MDS 2.0 Outputs a
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Application of RAI-MDS 2.0 Reports
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Case Study ApplicationThe Quality I
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Domain # Quality Indicators - Unit
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Domain # Quality Indicators - Unit
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4-35Domain # Quality Indicators - U
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InterRAI RAI-MDS 2.0 Quality Indica
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For Information: 416.327.7625 28ltc
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Strategies for Achieving RAI-MDS 2.
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RAI-MDS 2.0 Quality Improvement Too
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Comments:Part C: Use of Data for De
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Literature: Recommended Articles1.
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RAI-MDS 2.0 Nutritional Care Resource Guide April 2011 - CCIM

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