Comprehensive Guide to MDS 3.0 Section 0200: CAAs and Care Planning

Teaching a new MDS nurse how to complete Section 0200 of the MDS 3.0 form, which deals with Care Area Assessments (CAAs) and Care Planning. Here are detailed instructions on how to complete this section:

1. Check column A if Care Area is triggered:

• • This is the initial step in the process. You need to review the assessment data collected and determine if any of the Care Areas are "triggered." A triggered Care Area means that there is a potential problem or issue identified in the resident's assessment that requires further attention.
  • If a Care Area is identified as "triggered," mark "Yes" in column A. If there are no triggered Care Areas, mark "No."

1. For each triggered Care Area, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary:

• • For each Care Area marked as "triggered" in column A, you need to decide what action is required. This depends on the severity and nature of the identified problem(s).
• You have three options:
• a. New Care Plan: If the assessment data reveals a significant change in the resident's condition or a new problem that requires intervention, you must create a new care plan.
• b. Care Plan Revision: If there is an existing care plan, but it needs to be modified to address the newly identified problem, then revise the current care plan.
  • c. Continuation of Current Care Plan: If the resident's condition remains stable, and the existing care plan adequately addresses the issues, continue with the current care plan.
  • This decision should be documented in the "Care Planning Decision" column.

1. Indicate in the Location and Date of CAA Documentation column:

• • For each triggered Care Area that requires a new care plan or care plan revision, you must document where the information related to the CAA can be found.
  • The CAA documentation should include information on complicating factors, risks, and any referrals for the resident related to the specific Care Area.
  • This documentation should be completed within 7 days of finishing the RAI (MDS and CAA(s)) assessment.

1. Check column B if the triggered Care Area is addressed in the care plan:

• • After creating or revising the care plan for each triggered Care Area, go back and mark "Yes" in column B to indicate that the care plan indeed addresses the identified problems.
  • If a triggered Care Area is not addressed in the care plan, mark "No" in column B, and it means that the care plan needs further revision.

Completing Section 0200 accurately is essential for ensuring that residents receive the appropriate care and services based on their individual needs. It also helps in compliance with regulatory requirements and provides a basis for monitoring and improving the quality of care in long-term care facilities.