How to Write a RAP Summary for the MDS

The Resident Assessment Instrument (RAI) is a tool the federal Medicare and Medicaid programs require for use in skilled long-term and intermediate-care facilities. The RAI involves input by many departments in the health care facility; the nursing department is responsible for completing and verifying its information. The MDS (Minimum Data Set) sections are a major part of the RAI. The Resident Assessment Protocol, or RAP, contains statements that summarize the collected data in regard to a particular aspect of the resident's care. This RAP summary provides the rationale for interventions as part of an individual resident's plan of care.

Instructions

• 1

  Collect resident data through interviews and assessments. Social services, dietary, therapy, activities and nursing departments usually participate in the data collection. They use tools, forms and calculations to assess the resident's risk for various problems, such as malnutrition, skin breakdown, falls and more. Assessment information goes into the MDS sections of the RAI.

• 2

  Transfer the collected data to the MDS. Each section of the MDS pertains to aspects of the resident's medical profile. The completed MDS generates RAP sheets. Information from the MDS triggers the sheets. These triggers lead to the development of a comprehensive plan for that particular resident's care within the facility. The RAP summary prepares the nurse to begin the resident's plan of care.

• 3

  Compose the RAP summary in either paragraph or list form. The MDS person uses information from the checklist in the RAP. For example, the Falls RAP may list that the resident had two episodes of falling before he was admitted to the facility. The resident experienced a fractured hip as the result of one of those falls. Dizziness and vertigo are contributing factors. Prescribed psychotropic medications are other contributing factors; diuretic use is yet another. Summarize this and other information gleaned from all disciplines in the RAP summary.

• 4

  Use this summary as a rationale for formulating a plan of care using particular interventions to minimize or eliminate all risks and problems that could cause the resident to experience another fall.

  Here is an example of a RAP summary using the Fall model previously noted: "The resident has experienced two previous falls with one resulting hip fracture, both at home, while under the care of home health nurses and family members. Since admission, the resident's use of psychotropic medication has been discontinued and diuretic use has been changed to 'as needed' dosing. The resident has demonstrated short term memory impairment and has gotten out of bed several times without calling for assistance (See Nurses Notes from 12/3/10 and 12/5/10). A plan of care has been implemented to minimize the resident's chances for experiencing future falls."

• 5

  Review the RAP summary before printing it since it is a part of the resident's permanent record. Check spelling and sentence structure. A poorly done RAP summary affects the the plan of care, since the same person completes both. A well-composed RAP summary enhances the resident care plan and gives the MDS nurse credibility with those reviewing the RAI.