NZ Best Practice Guidelines for Completing LTCF Assessments

interRAI Assessments are legal clinical records. All coding and comments must accurately reflect the resident’s status at the time of assessment and comply with the designated assessment timeframes.

Overview Page

The following fields are mandatory (all other fields are optional, so check what your facility requires):

• Marital Status

• Primary Language and Secondary Language

• Interpreter Required

• Ethnicity — Ask the person: “Which ethnic group do you belong to?”

• The provider is the person responsible for completing the current assessment
• Delete the previous provider’s details before proceeding, unless both names are required by your facility

Disease and Diagnoses
History

Enter each diagnosis separately, ensuring the following fields are completed:

• Description – Enter the name of the diagnosis or condition. Common abbreviations are acceptable. Click here for the list of acceptable abbreviations

• Date Identified – The default setting is Unknown

• Status – The default setting is ‘Active’. Historic diagnoses no longer affecting the person can be recorded as ‘Inactive, cured or in-remission’

• Use in MDS/Assessment – Tick this box if the diagnosis is not listed in the assessment Disease Diagnoses Section I1 options.

Assessment

In your own words:

• • Code the assessment items as per the interRAI Long Term Care Facilities (LTCF) Form and User's Manual or interRAI Assessment Software (iAS) section help guidelines ℹ️

  • Consider including notes to provide additional details about the resident’s conditions, challenges, tikanga and cultural preferences, or history

  • Use these notes to support coding decisions and enhance care planning

  • Update or remove auto-populated coding and notes from the previous assessment if they no longer reflect the resident’s current status, ensuring the clinical record remains accurate

  • If there are discrepancies in the information provided about a resident, note any conflicting points of view

  • Coding for self-reported items should be based solely on the resident’s responses. If they could not/would not respond, code “8”

  • Ensure abbreviations are clear to all who may read the assessment. If in doubt, write them out in full. A list of common abbreviations is included at the end of this workbook

  • Include cultural information if shared by the resident, such as their place of origin, iwi affiliation, and any customs or principles (tikanga) they identify as important

  • Summarise key issues identified in the assessment in the Assessment Summary page to help guide care planning

Assessment Summary 

In your own words:

• • Summarise the person’s issues/problems identified by elevated/adverse Outcome scale scores
  • Summarise the person’s issues/problems identified by triggered CAPs (risks, opportunities to improve, prevent decline, or alleviate symptoms)
  • Summarise any additional issues identified in the assessment that are not identified by Outcome scale scores or triggered CAPs
  • Note outward referrals being made to clinical teams or community organisations
  • Note a clinical reason if you are deciding not to address a triggered CAP

Tick the ‘Addressed in Care Plan’ box for all CAPs you are care planning.