Skilled Nursing Facilities

MDS 2.0 - Section V - Narrative CAPs

If your facility is using Clinical Assessment Protocols (CAPs), you can complete CAPs triggered by the RAI-MDS 2.0 assessment using a narrative-structured format. The triggered CAPs must be signed before completing section V and locking the assessment.

  1. From the MDS tab of the resident chart, click Edit next to the MDS assessment.

  2. Edit Section V.

  3. Edit the CAP to work. The CAP window appears, and shows the following information for each CAP triggered:

    • Resident Name, Description of the RAI-MDS 2.0 assessment type, and ARD.

    • Name of CAP Problem Area, a check mark appears if this CAP is triggered, and the CAPType.

    • Triggered By indicates which response(s) on the MDS assessment triggered this CAP. These triggers follow the matrix for determining which CAPs must be worked as per the CIHI guidelines.

    • Location of CAP Documentation field is present so that you can enter the location of where the CAP documentation was entered (Ex. progress note, UDA, notes field in the CAP window that appears).

    • You can also select whether to Proceed or Do Not Proceed to address this CAP in the resident's care plan.

    • Enter notes in the Additional Notes section.

  5. Triggered CAPs must be signed when the documentation is complete. Click Sign next to the triggered CAP.

  6. Location of Documentation - you are required to select at least one:

    • If you documented within the CAP, select CAP Worksheet.

    • If you used a progress note to document your CAPs process, select Progress Note and enter your position and the date of the progress note written to address the CAP.

    • If you used another means of CAPs documentation, select Other and enter the location of your documentation in the text box.

    • If you used an assessment to document your CAPs process, select CAP UDA/Other UDA.

    • If you used a care plan to document your CAPs process, select Care Plan/Care Plan Review.

  7. Click Sign.

  • After a CAP is complete, the 'Location and Date of CAP Assessment Documentation' column shows the documentation details. Also, the edit link changes to a view link and the sign link changes to a reopen link.

  • You can record your care plan decisions within each CAP, or by clicking Care Plan Decisions. Select Yes or No for each CAP triggered then click Save to record your care plan decisions.

  • If 'Require users to sign off on non-triggered CAPS' is set to Yes in MDS Configuration, you are required to sign a non-triggered CAP if the Care Plan Decision is set to Yes.

  • In the MDS Portal (Clinical > MDS) > In Progress tab, you can see all in progress MDS assessments. Here you can edit the MDS to work your CAPS, as opposed to going to the MDS tab of the resident chart.

  • CAPS can be enabled with the appropriate security permissions through Clinical > Setup > MDS Configuration > CAPS Options.

  • You must have appropriate security permissions for section V of the MDS to work CAPs.

  • You must have appropriate security permissions to see the MDS Portal.