What are the three most important records in a nursing home?
#1: Minimum Data Set (MDS): The Minimum Data Set is a comprehensive assessment of the resident's functional capabilities and helps the nursing staff identify health problems. Certain items on the MDS will indicate that a resident is at risk, i.e. falling, pressure sores, urinary tract infections, etc. When a MDS shows a health problem, it triggers the Resident Assessment Protocol.
#2: Resident Assessment Protocol (RAP): After the Minimum Data Set is completed, a resident who has one or more risks (known as "triggers") will trigger a Resident Assessment Protocol. This form is to provide clues as to risks presented by residents in nursing homes. The Resident Assessment Protocol is the foundation upon which a resident's individual Care Plan is formed.
#3: Care Plans: The Care Plan should contain interventions to minimize injuries. Examples of such interventions include the use of a sitter and the use of bed and chair alarms for residents at risk of falling.