Document the dementia-specific skilled element each day it applies:
The dementia baseline and today’s status, and — critically — any acute change or fluctuation suggesting delirium superimposed on dementia (CAM), which warrants a medical-cause screen.
Behavioral and psychological symptoms (agitation, aggression, resistance to care, wandering, psychosis) — the pattern, triggers, and any new or dangerous escalation requiring skilled management.
Safety (falls, wandering/elopement risk, and danger to self/others) and, where a skilled comorbidity is present, how the dementia affects that plan.
MDS-supportive data
Cognition and delirium features are coded in MDS Section C, mood in Section D, behavior in Section E, and dementia in Section I. The record must document the baseline, any superimposed change, and the behavioral management so the MDS is supported.
