For Section F, what should the progress note include?
Q: In reference to MDS 3.0 Section F, what should the progress note include? Should the note address each of the categories and explore what the resident finds important? I have been writing longer notes for fear of missing an aspect. I then write a second note after re-interviewing a person who triggered for section F due to another section’s answers. The process, of course, is interesting. I just want to spend more time with the resident’s and less with their notes!
A: The principal theme of Section F is to identify those things that are important to the resident so that care is provided based on the resident’s preferences. Section F responses cross many different disciplines, all of which should address the details of the residents routines and preferences as they are learned. It is not necessary to address every response specifically or in one note. Any relevant information obtained can be addressed in different notes at different times. For instance, the CAAs may include some resident specifics, care plans may include others, and IDT notes should address those that impact the services each discipline provides based on a residents needs, interests, clinical status, functional capacity and preference. Writing lengthy, detailed notes is not always helpful to the resident. Address the details where you get the most benefit for the resident.