Abstract

Clinical decisions related to patient care must be preceded by the process of gathering information about physical, functional, and psychosocial condition. The mandatory tool used in nursing facilities in the USA is the Minimum Data Set (MDS). MDS helps to identify each resident’s functional capabilities and health problems in preparation of optimal and individualized plan of care. The final outcome of the analysis of the collected data is an individualized care plan for each patient. The purpose of the paper is to present MDS tool application in the process of planning care for an elderly person and its impact on clinical decisions. This paper delineates the way the MDS tool is used, as well as functions of the respective members of the team providing care for a patient. The observations and assessment of the practical use of MDS were presented using the example of a patient (66 years old) with significant pain complaints (primary diagnosis: lung tumor with metastasis into bones). A care plan that is based on a thorough assessment, effective clinical decision making, and that follows current standards of clinical practice can provide a strong foundation for optimal approaches to quality of care and can help to determine the amount of clinical resources used in order to determine payment for services.

Key words:

Minimum Data Set, nursing facilities, care planning