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

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The College of Dietitians of OntarioDocumentation Requirements adapted forLong-Term CareThe College of Dietitians of Ontario developed a “Record Keeping Guidelines for Registered Dietitians 2004”. Theguidelines are available to Dietitians to interpret and accompany the record keeping regulations.This document provides practical information on record keeping and documentation standards for RegisteredDietitians (RDs) to meet their professional, legal and ethical obligations. These guidelines apply to all practice settingsregardless of the type of system or method used.Dietitians can play an important role in ensuring that workplace systems, processes, policies and procedures facilitatethe implementation of record keeping and documentation guidelines. Within each home, the dietitian is required tofollow home specific policies around record keeping as well as any regulations or legislation, which exists fordocumentation.For Information: 416.327.7625 18ltchrai@ontario.ca18
The College of Dietitians of OntarioDocumentation Requirements adapted for Long-Term CareItemDocumentation Requirements Adapted forLTCBased on the College’s Proposed RecordsRegulation1 The client health record includes the date ofeach of the client's visits to the dietitian or by thedietitianSection (7)(b) of the College’s ProposedRecords Regulation2 The client health record includes the reason forthe referral. Section (7)(d) of the College’sProposed Records Regulation3 The client health record includes the client’srelevant medical history including medical andsocial data related to nutritional intervention.When background health information has beenprovided by another practitioner, it need not beduplicated; however, a reference to theappropriate section must be included. Section(7)(e) of the College’s Proposed RecordsRegulationRecommended Application to RAI-MDS 2.0There is no designated location in the RAI-MDS 2.0 to capture residents’ visitsby the dietitian. Dietitian can document his/her visits under the RAP or nontriggeredclinical problems assessment summary or in progress notes.Reason for referral can be documented under Step 4 of the RAP assessmentsummary or in the progress note. A RAP assessment summary has 5components or steps that the help guide the professional through theassessment process.1. Type of RAP2. Nature of the problem3. Key issues that contribute to the RAP4. Need for referral and reason for the referral5. Care planning decisionIn the Appendix, a sample Dietitian Referral Form contains examples ofreason for the dietitian referral.The RAI-MDS 2.0 is an interdisciplinary tool. In documenting the client care, itis important to clearly indicate what information was used to form yourassessment and care plan. Where information has been gathered andrecorded elsewhere in the client record, there is no need to repeat thatinformation, as long as it is referenced in the nutrition assessment. Forexample, if information contained elsewhere in RAI-MDS 2.0 (e.g. section H) isrelevant or has the potential to be relevant to the nutrition assessment andcare plan, it would be appropriate to simply state “see RAI-MDS 2.0 section H2regarding bowel elimination pattern.”. Other examples would include “see SPL swallowing assessment note of May 13th, 2008” “see Nursing notes of June 2 nd , 2008” “see Food and Fluid intake records of May 5-10, 2008To avoid the perception that problems have been overlooked in theassessment process, all relevant, or potential to be relevant clinical concerns,should be documented in the progress notes or in the RAP/non triggered RAPassessment summary.Dietitians can trust the assessment entries/coding made by theirinterdisciplinary team members; however, there may be circumstances wherethe information recorded in the chart should cause the dietitian to questionsomeone else’s entries. Validation of the assessment by the other members3-37 of the team is a natural part of the process.Decisions to care plan or not to care plan some of the RAPs or non-triggeredclinical problems can be documented under Step 5 of the RAP Care PlanningDecision or in the progress notes depending on the individual home’s policy.For Information: 416.327.7625 19ltchrai@ontario.ca19
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RAI-MDS 2.0 Nutritional Care Resour
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Table of Contents1. Chapter 1: RAI-
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Glossary of TermsADLAlgorithmAverag
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RAI-MDS 2.0 Target population:Frail
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SECTION F: PSYCHOSOCIAL WELL-BEINGI
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SECTION P: SPECIAL TREATMENTS AND P
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SECTION V - RESIDENT ASSESSMENT PRO
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OUTCOME SCALES OR MEASURES• 10 ou
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Getting Started ChecklistCompletion
Page 19 and 20: Selected Coding Sections of RAI-MDS
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
Page 69: RAPS and Care Planning Software Ori
Page 73 and 74: 8 Documentation by the dietitian in
Page 75 and 76: 17.10 Draws relevant conclusions fr
Page 77 and 78: RAPProcessLeaves25% ormore foodunea
Page 79 and 80: RAP Process Step 1Type of RAPLeaves
Page 81 and 82: Dietitian ReferralDietitian Referra
Page 83 and 84: 13. Dental Care14. Pressure UlcersD
Page 85 and 86: New triggered RAPs affecting nutrit
Page 87 and 88: Criteria to Review4. Evidence of RA
Page 89 and 90: OverviewOVERVIEW• Getting started
Page 91 and 92: MoodWorsened mood - symptoms of dep
Page 93 and 94: 15. Prevalence of depression withou
Page 95 and 96: • E1l - Sad, pained worried facia
Page 97 and 98: AGGRESSIVE BEHAVIOUR SCALE (ABS)•
Page 99 and 100: • Hemiplegia, pneumonia, septicem
Page 101 and 102: Preparing for RAI-MDS 2.0 Outputs a
Page 103 and 104: Application of RAI-MDS 2.0 Reports
Page 105 and 106: Case Study ApplicationThe Quality I
Page 107 and 108: Domain # Quality Indicators - Unit
Page 109 and 110: Domain # Quality Indicators - Unit
Page 111 and 112: 4-35Domain # Quality Indicators - U
Page 113 and 114: InterRAI RAI-MDS 2.0 Quality Indica
Page 115 and 116: 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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