Documentation, MDS and care planning

One of the new information I have gained is that Just because section F is not included in
the quarterly MDS, it does not mean that the Activity Department shouldn’t continue with their
quarterly progress notes or other episodic notes. I also learnt that it is very important that the
Activity Professional monitor each resident’s responses to activities and any activity
interventions in accordance with the care plan. Quarterly and episodic notes help the Activity
Professional to determine if changes should be made to care plans or if a change in the type of
programming provided is needed.
Documentation is very important because it is assumed that if something was not
documented, then it did not happen. Documentation ensures that there is continuity of care on an
individual and serves as a communication tool for all health care providers. Documentation is
important for evaluation and planning of a patient’s treatment. Documentation also creates
permanent records for the patient the can be used for the care of that patient in future. Apart from
documentation, I also learnt that Minimum Data Set (MDS) is a clinical assessment of every
resident in Medicaid or Medicare certified homes. The forms must be filled regardless of the
payments source of the residents. I also learnt that once the MDS forms are filled, the
information would be available in the databases of CMS (Centres for Medicare and Medicaid
Services) because they would be received there electronically. I also learnt that care planning is
very important for the future health of an individual.