Chapter 21 Federal Regulations

TABLE 21.6 Clinical Problem-Solving and Decision-Making Process Steps and Objectives Process Step/Objectivesa Recognition/assessment

Key Tasksb ● Gather essential information about the individual.

Identify and collect information that is needed to identify an individual’s conditions that enables proper definition of his or her conditions, strengths, needs, risks, problems, and prognosis.

● Obtain a personal and medical history. ● Perform a physical assessment.

Problem definition Define the individual’s problems, risks, and issues.

● ●

Identify any current consequences and complications of the individual’s situation (eg, underlying condition and illnesses).

Clearly state the individual’s issues and physical, functional, and psychosocial strengths, problems, needs, deficits, and concerns.

● Define significant risk factors. Diagnosis/cause-and-effect analysis

Identify physical, functional, and psychosocial causes of risks, problems, and other issues, and relate to one another and to their consequences.

● ● ●

Identify causes of, and factors contributing to, the individual’s current dysfunctions, disabilities, impairments, and risks.

Identify pertinent evaluations and diagnostic tests.

Identify how existing symptoms, signs, diagnoses, test results, dysfunctions, impairments, disabilities, and other findings relate to one another.

●

Identify how addressing those causes is likely to affect consequences.

Identifying goals and objectives of care

Clarify purpose of providing care and of specific interventions, and the criteria that will be used to determine whether the objectives are being met.

Selecting interventions/planning care

Identify and implement interventions and treatments to address the individual’s physical, functional, and psychosocial needs, concerns, problems, and risks.

● Clarify prognosis.

● Define overall goals for the individual. Identify criteria for meeting goals.

● ● ●

Identify specific symptomatic and cause-specific interventions (physical, functional, and psychosocial).

Identify how current and proposed treatments and services are expected to address causes, consequences, and risk factors, and help attain overall goals for the individual.

● Define anticipated benefits and risks of various interventions. ●

Monitoring of progress

Review individual’s progress toward goals and modify approaches as needed.

● ●

Clarify how specific treatments and services will be evaluated for their effectiveness and possible adverse consequences.

Identify the individual’s response to interventions/treatments.

Identify factors that are affecting progress toward achieving goals.

● Define or refine the prognosis.

● Define or refine when to stop or modify interventions. ●

● Adjust interventions as needed. ●

Review effectiveness and adverse consequences related to treatments.

Identify when care objectives have been achieved sufficiently to allow for discharge, transfer, or change in level of care.

aRefers to key steps in the care delivery process, related to clinical problem-solving and decision-making bRefers to key tasks at each step in the care-delivery process

Source: Centers for Medicare & Medicaid Services. MDS 3.0 RAI Manual v1.13:4-7. www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html. Accessed October 15, 2015.

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