One of the most frequently asked questions during our facility site visits is about how to improve the accuracy in coding of Section G; ADL Functional Status. The answer is always education, education, education! Staff turnover and "urban myths" about coding are two barriers that make frequent education a must.
Here are the Top 10 ways to Keep Your ADL Coding up to Snuff:
1. Provide staff with the definitions for coding ADL self-performance and support provided: Review the definitions as they appear in the MDS 3.0 RAI User’s Manual on a regular basis.
2. Use consistent terminology for assessing and documenting ADLs using the RAI User's Manual terms to avoid miscoding: Avoid using different terminology for ADL functioning from Nursing staff and Rehabilitation Staff. Whenever possible, encourage the staff to use the common language of the MDS.
3. Consider all components of an ADL, with focus on bed mobility and toileting: Break each ADL task into sub-tasks. The patient may do well in one part of an activity, but need more assistance for another task of the ADL. Remember that toileting includes transferring to the commode and donning/doffing clothing and personal hygiene. If a resident requires assistance to dress and bath, he or she most likely requires weight-bearing assistance 3 or more times in the last seven days for toileting.
4. Obtain a complete picture of the patient’s function, including times when the person is most dependent: When reviewing progress notes, be mindful of ADL references, including documentation outside of the 7 day look back period. It is likely that the resident’s ADL status during the assessment period will be similar to that referenced in earlier or even later record entries.
5. Make sure the patient’s medical record provides the information required to support/code the late loss ADLs: Ensure CNAs complete all sections of the ADL flowsheets, especially the late loss ADLs, on a daily basis and that there are nursing notes describing patients’ performance and support levels.
6. Use simple MDS terminology on the ADL flowsheets: Define extensive and limited assist in simple terms to ensure the CNA staff have a clear understanding of the levels of assistance.
7. QA: Have a process to review ADL flowsheets for accuracy and completeness.
8. Use all sources of information for coding ADLs on the MDS: Observe the patient during at least 2 of the late loss ADLs if there is any question regarding accuracy. Often, eating and transferring are the most meaningful and easiest to observe in order to validate ADL coding.
9. Consider validating the daily ADL coding by the CNA staff and provide time for documentation several times per shift: CNAs often rely on memory when documenting assistance provided for ADLs at the end of their shift and often may not record the level of care they provided at the beginning of their shift. This may lead to make a guess or copy cat coding from the previous shift or previous day.
10. Nurses should not use the therapy documentation as a guide for their own documentation of patients’ ADL status: Encourage nurses to document what they observe, participate in, and what is reported to them.
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