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Test your knowledge answers:

1) Follow up with the nurse to clarify when the shortness of breath occurs, either with exertion, when sitting at rest, when lying flat, or possibly during none of these. If the answer doesn’t fit into the three options in J1100, it just doesn’t have a home on the MDS.

2) Many electronic software MDS programs can pull “answers” for section G from different sources. Check an audit report to see where the answer(s) were pulled from. Keep in mind, that the steps for assessment and coding instructions do not include pulling data from other software. You really have to review the chart, talk to staff, observe, and clarify/verify to satisfy the requirements of the RAI User’s Manual. That’s what the signature at Z0400 says has been done.

3) Per the RAI User’s Manual, nothing would be done to change the original DCRA, as that was the plan when the resident left. Since the resident did return within 30 days, you will complete an Entry Tracker for the re-entry and put them back on the OBRA schedule where they left off, assessing for a Significant Change in Status Assessment (SCSA) in the meantime.

4) No. Even though the resident did not have a new hospital stay, there was a new Medicare A start date. If the DRR was not completed on this new Medicare start date, you would need to dash N2001.

RAI User’s Manual page N-16:

Complete a drug regimen review upon admission (start of SNF PPS stay) or as close to the actual time of admission as possible to identify any potential or actual clinically significant medication issues.

5) The OBRA DCRNA would be completed and if the resident is gone for at least three midnights, you will also add the End of Medicare Stay (Part A PPS Discharge Assessment) to the OBRA DCRNA.