MDS Essentials: Tracking /Discharge MDS;Entry

The Minimum Data Set (MDS) 3.0 includes specific assessments and tracking forms designed to capture important information about residents' status at various points during their stay in a nursing facility. Among these, the Entry and Discharge Tracking forms are essential for documenting significant transitions. Here is an overview of the Entry Tracking Form within the MDS framework, focusing on its purpose, components, and how it fits into the overall resident assessment process.

Purpose of the Entry Tracking Form:

The Entry Tracking Form is designed to document key information when a resident is admitted or reenters a facility. Its primary purposes include:

• Initial Documentation: Captures essential data at the time of a resident's admission or reentry, setting a baseline for care planning.
• Regulatory Compliance: Meets federal requirements for tracking resident movements in and out of the facility, which is crucial for compliance and funding considerations.
• Facilitation of Care Planning: Provides immediate information that can be used to initiate care planning, even before the completion of a comprehensive MDS assessment.

Components of the Entry Tracking Form:

The Entry Tracking Form includes several key pieces of information:

1. Resident Identification: Basic demographic information, including name, date of birth, and Social Security number.
2. Admission/Reentry Information: Dates and details about the resident's admission or reentry, including the source of admission (e.g., from home, hospital, another facility).
3. Initial Resident Status: Brief indicators of the resident's health status upon admission or reentry, which may include information on significant diagnoses, functional status, and immediate care needs.
4. Documentation for Tracking: Fields to document the specific reasons for the entry tracking, such as distinguishing between a new admission and a reentry.

Implementation and Timing:

• Upon Admission/Reentry: The Entry Tracking Form should be completed as soon as possible upon a resident's admission or reentry to the facility to ensure timely documentation.
• Before Comprehensive Assessment: While the Entry Tracking Form provides an initial snapshot, it precedes the more detailed comprehensive assessment that must be completed within the regulatory timeframe.

Integration with MDS Assessments:

• Transition to Comprehensive Assessments: The information from the Entry Tracking Form can be used to inform and expedite the completion of the comprehensive MDS assessment, which is required for all residents and provides a detailed evaluation of the resident's needs for care planning.
• Continuity of Care Documentation: The Entry Tracking Form, along with the Discharge Tracking Form, ensures continuity of documentation throughout a resident's stay, from admission through discharge, facilitating a comprehensive view of the resident's journey through the care continuum.

Conclusion:

The Entry Tracking Form is a crucial component of the MDS 3.0, serving as an initial documentation tool that captures vital information at the point of a resident's admission or reentry into a nursing facility. By providing a timely snapshot of the resident's status, it supports regulatory compliance, facilitates early care planning, and contributes to the continuity of care documentation essential for high-quality, person-centered care.