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

Resident Assessment Protocol (RAP) Auditing Tool – OptionalResident Name:______________ Unit: ______________ Type of Assessment: _________________Criteria to Review1. Completion of the Section V: RAP Summary Form. Present NotPresentA. Column (a), check if triggered (this may be checked by the softwareautomatically)B. Location and date of the current RAP assessment documentation(references to various locations in the chart such as: consultation notes,M.D. orders and notes, therapy notes, nurses’ notes etc.)PartialC. Column (b), check if RAPs documentation indicates that care planning isrequiredD. Signature of RN/RPN at VB1E. Date of VB2 (Completion of RAPs)F. Signature at VB3G. Date of VB4 (Completion of the Care Plan, Vb3+Vb4)2. Accurate Timing of RAP and care plan completion:In Section V: Resident Assessment Protocol Summary formA. VB2: for quarterly, annual and significant change: ARD + 7 daysVB2: for new admission: AB1a (Admission Date) + 14 days or ARD + 7daysB. VB4: for quarterly, annual and significant change: ARD + 14 daysVB4: for new admission: AB1a (Admission Date) + 21 days or ARD +14 days3. RAP Assessment Summary ReviewA Use of the 5-steps template by interdisciplinary team membersB Evidence of non RAPs clinical problems identifiedCDEFGType of RAP identified (new, existing or adjusted)Nature of the problem clearly stated (Identifying data thatcontribute to the assessment)Key issues that contributed to the RAP (causative factors,complications, risk factors, impact on resident’s daily functioningand effectiveness of care planning interventionsFurther assessment and or need for referrals identified. Statereason for referralCare planning decision stated (if not, state why is the RAP not aproblem for the resident)3-93For Information: 416.327.7625 34ltchrai@ontario.ca34