​Before under-coding can be alleviated, it is imperative to identify the root causes of the problem and any obstacles to corrective action. Four pervasive problems directly attributed to documentation include the following: 

Copying. In most cases, facilities use paper charting forms, or flow sheets. Unfortunately, employees
sometimes attempt to save time by simply copying what the previous shift documented instead of making their own assessment. 

Rule of Three. Most flow sheets only allow each ADL to be documented once per shift. Obviously, many residents eat, are transferred, and ar e toileted multiple times during any shift. Missing out on the opportunity to document multiple occurrences increases the likelihodd of missing the "rule of three" to capture incidents of higher dependence. 

Education. Oftentimes, inaccurate documentation originates from inadequate education provided to nurse assistants. That is why it is important to determine if employees truly understand the difference between
limited assistance and extensive assistance. Some care providers believe that the difference is related to the amound of the task the resident is able to perform. According to the MDS, limited assistance is when the resident is highly involved in the activity and employees only provide guided maneuvering of limbs or other
non-weight-bearing assistance. On the other hand, extensive assistance requires employees to provide weight-bearing assistance along with resident involvement. Other repetitive issues occur because employees do no understand the full explanation of an MDS item. For instance, with bed mobility, many employees identify that this incorporates the resident's ability to turn from side to side. Often missed is the frequency of “how resident moves to and from a lying position,” which generally requires more weight-bearing assistance from the staff. Toilet use is another area that is frequently miscoded as it does not just pertain to residents that use the toilet. It also includes residents that utilize a commode, bedpan, or urinal. 

Oversight. While chart audits are both time-consuming and challenging, they are the only method to know if paper documentation has been missed or is inaccurate. Random chart audits are an important but sometimes neglected tool.