To print or not to print, that is the ?

[rukiddingme]

I have only been working with MDS' for 2 years, and both facilities I've worked in have always printed out the MDS' (after putting in everyone's information they've given us) then pass them around for the other departments to sign, then file into binders. We are the only 2 that input data for the MDS. My MDS Supervisor said she's always done it this way -but she likes the idea of paperless, but knows nothing about it either.

We currently use MDScare by LTC solutions. I just wondered how do you go 'paperless' and what would be the pro's & con's of it? Thanks alot for any input anyone has. Tara

[SuesquatchRN, BSN, RN]

It has to be a part of the system's design. Basically, I can't because I don't have rights to that signature line. Only authorized people can sign off and that sign-off is as good as an ink signature. Different people are authorized to different signatures.

[edhcinc]

Hi!

The "signoff" is part of the software--the name/credentials of the person who completed an item are automatically identified by his/her system and software login. The date and time of completion automatically "defaults" to the actual system date/time. Your system SHOULD NOT ALLOW these values to be changed unless your security policies allow another authorized user to change/correct information prior to the R2b completion date--at this point, the system records the signoff associated with each data item.

The printed MDS would indicate these signoffs--name, section (or item) and date, at AA9. If NOT printed, each software system must be able to show (on screen) who did what and when, and also to print a report with this information.

Other security policies may (and SHOULD) be in place to maintain "data integrity" and prevent/limit access or modification, record attempts to change info by unauthorized users, and log changes made by a "system supervisor" (and restricted/allowed under specific unusual circumstances only). If you do not have, or do not follow basic data security "rules", you should not claim that you maintain an electronic MDS/RAI system. The most basic security rule requires individual person specific login-ins, automatic password complexity and frequent password changes.

If the MDS or EMR software incorporates and the facility uses/enforces MDS completion "rules" and HIPAA/state/local security "rules", staff non-compliance becomes immediately obvious.

• Sections show up as completed by Jane, tho actually completed by Sally--Because Jane did not log out of software, and Sally did not log in.
  
• Sections show up as completed by Jane, tho actually completed by Sally, because Jane data-entered Sally's work.
  
  
• Sections show that they were completed before the ARD
  
• A section completion date may be after the R2b date.
  
  
• R2b may indicate completion and signature of the LPN MDS coordinator, rather than the responsible RN. Worse, yet, the LPN may be required (and told that he/she will lose his/her job if not done) to log with the password of the responsible RN and fraudulently enter the RN's electronic signature and date.:uhoh21:
  

Unfortunately, as we know, even if the MDS IS printed, no one may read it. Printing it just to make the surveyors happy is an unnecessary use of resources--they can easily (and sometimes more easily) find and read what they need electronically.

There are plusses and minuses whatever we do now. We need to get used to electronic; but we cannot USE it as the legal record unless we "get with the program"--and comply with all the required security components.

Good luck to us all!

[rukiddingme]

:yeah:Thank you for that information - I found it very insightful, and eye-opening. Not sure electronic would work well for my facility. Guess we'll just keep "cutting down more trees" for all the paperwork. Tara