MDS Care Plans: A Person-Centered, Interdisciplinary Approach to Care

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MDS Care Plans: A Person-Centered, Interdisciplinary Approach to Care

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MDS Care Plans: A Person-Centered, Interdisciplinary Approach to Care

Debbie Ohl, RN, M.Msc, PhD

Looking to develop a more comprehensive plan of care while improving MDS 3.0 accuracy? MDS Care Plans: A Person-Centered, Interdisciplinary Approach to Care helps you navigate recent changes to the RAI and includes more than 100 customizable care plan templates. With many updated regulations already in effect, this timely book covers the IMPACT Act, QAPI, person-centered care, and survey changes, as well as the changes resulting from the ICD-10 transition.

Each care plan provides a framework for guiding the review of trigger areas and clarifying a resident’s functional status and related causes of impairments. It also provides a basis for additional assessment of potential issues, including related risk factors. These thorough assessments provide the interdisciplinary team additional information to help them develop a comprehensive plan of care. By modifying the care plans provided in this resource, you’ll fit the individual needs of your residents while satisfying the requirements of the new assessment process.

This product will help facilities:

  • Save time developing person-centered care plans using more than 100 customizable templates
  • Evaluate and create valuable Care Area Assessments (CAA) and improve MDS 3.0 accuracy
  • Help customers navigate recent changes to the RAI
  • Integrate the voice of the resident, family, and staff in the development of the care plan
  • Be confident they’re making use of proven tools and expert guidance


Table of Contents

Chapter 1: Evolution of Care Planning
Chapter 2: MDS 3.0 Implications for Care Planning
Chapter 3: QAPI: Focus on MDS
Chapter 4: Creating Person-Centered Care Plans 
Chapter 5: Triggered Quality Indicators 
Chapter 6: How to Use the Care Plans in This Manual 
Bonus Online Chapter: Federal Certification Requirements
Appendix: Care Plan Index – More than 100 modifiable care plans in 21 categories: 
Active Disease Diagnosis 
Activities 
Behavior, Mood, Well-Being 
Bladder Plans 
Bowel Plans 
Catheters 
Cognition, Dementia 
Communication 
Dehydration 
Dental 
Falls 
Health Conditions 
Infections 
Medication 
Nutrition 
Pain Management 
Restorative Nursing 
Sensory 
Skin Conditions 
Social Service 
Special Procedures


About the Author

Debbie Ohl, RN, M.Msc, PhD, is a successful consultant and author of more than 25 years. She is owner and senior consultant at Ohl and Associates, a consulting practice dedicated to promoting quality outcomes and professional excellence in nursing facilities. Ohl is a registered nurse, nursing home administrator, skilled geriatric clinician, nursing home consultant, educator, and author. She is an expert in nursing facility regulatory guidelines and clinical practice, specifically assessment and care planning.

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If for any reason this product does not meet your needs, return it within 30 days and you will receive a prompt, polite, 100% refund—no questions asked. We guarantee it!


Published: March 2016

Page count: 402
Dimensions: 8.5x11
ISBN: 978-1-55645-899-6