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Long-Term Care Assessments

  • Updated

The assessment forms for Long-Term care are completed in the following sequence:

  1. Admission/Re-entry form
  2. Full Assessment
  3. Quarterly assessment

RAI-RC assessments have multiple tabs corresponding to the different sections of the paper version (See Link to Downtime forms Long-Term care). Each section needs to be section completed. R2a/b and CAPs needs to be signed-off by the due date.

Admission/Re-entry

  1. Click on Assessments application Assessments.png
  2. For a newly admitted resident, create and complete RAI-RC ADMISSION/RE-ENTRY by clicking on create a new assessment CreateAssessment.png.
  3. Complete following mandatory fields:

a.   Header tab

 

Date started

Enter date

b.   Tab AAA

AA6

Facility Number

See instructions to search

c.   Tab AB

AB1

Admission/

Re-entry date

Enter correct date
  1. Save

NOTE: The Facility number, Admission date and the Admission form assessment ID, is used to create the Unique Registration Identifier (URI) as indicated on Section AA1 of all RAI-RC 2.0 assessments. The URI is a reference number for data submission.  Once the Admission form is created, the URI cannot be corrected.

  1. To enter codes in the assessment, you can generally point and click on the response item and the code will populate the boxes on the right. Some items will require direct input.
  2. At the end of each section, tick Section complete and choose your name. Your name and current date should appear.

NOTE:  Sections that are section completed will lock as read-only. To modify, untick the section complete to release the lock.

  1. Once all the sections are completed, the assessment can be signed-off by choosing your name from the picklist on R2a on the Signatures section.

NOTE:  Signing off R2a will close the assessment and make it read-only.


Downtime forms Long-Term care

Search facility number


Full/Quarterly Assessment

  1. Click on assessment application Assessments.png
  2. Click on create a new assessment CreateAssessment.png
  3. Assessment code = MDS*
    • Search
    • Select correct assessment from the list (Full or Quarterly)
  4. Complete mandatory/required fields
  • Header Tab                      Date started:  Enter date
  1. Save
  2. Enter the correct Assessment Reference Date (ARD) on A3
  3. To enter codes in the assessment, you can generally point and click on the response item and the code will populate the boxes on the right. Some items will require direct input.
  4. At the end of each section, tick Section complete and choose your name. Your name and current date should appear.

NOTE:  Sections that are section completed will lock as read-only. To modify, untick the section complete to release the lock.

  1. Once all the sections are completed, calculate CAPs (Link instructions) to review the results of your coding. Make necessary changes as appropriate.
  2. Once coding is final, sign-off by going to Section R and choosing your name from the picklist on R2a. Signing off R2a will make all entries for Sections AAA - U read-only.
  3. On the CAPs section, document the decision on each CAP item.
  4. Save
  5. Sign-off the assessment by clicking on the CAPs Signature and choose your name.

Note:  Signing off CAPs will close the assessment and make it read-only.

  1. Save

Discharge Form – (For final discharge only. Client moved to a different facility, outside of health area or Deceased)

  1. Click on assessments application tile Assessments.png
  2. Click on create a new assessment CreateAssessment.png
  3. On the (Assessment type) Search form, Enter Assessment code = MDS*
    • Search
    • Select correct assessment from the list (DISCHARGE FORM)
  4. Complete mandatory/required fields
    • Header Tab               Date started:  Enter date
  1. Save
  2. To enter codes in the assessment, you can generally point and click on the response item and the code will populate the boxes on the right. Some items will require direct input.

NOTE:  Sections that are section completed will lock as read-only. To modify, untick the section complete to release the lock.

If resident was transferred to another facility, search for facility codes (R3b).

If facility number cannot be found, search using *NON* on the Description to search for Non-VCH facility

If resident was deceased, discharge date (R4) = date of death.

  1. Once all the sections are completed, the assessment can be signed-off by choosing your name from the picklist on R2a on the Signatures section.
  2. Save

 

Search facility number

 

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