I need to just make sure I have this right...
First of all I am in Texas, working at a skilled nursing hospital about an hour North of Austin. We are Medicare only certified. I am pretty new to the world of MDS but determined to eventually know it inside out, if that is possible! I am the obly MDS person here so there is no one with years of experience and knowledge to go to. But this board has been a blessing and I have learned much.
'Here', I use an electroniic MDS program provided via Keane Care (VistaKEANE). I am able to electronically sign my signature as is our pharmacist. I only PRINT the section V (CAA and CP) and the section Z (Billings and Signatures). I put the CAA/CP section on the patients hard copy record here, which then goes directly to Med Records on discharge where it is all scanned into an electronic medical record program called Sequoia. The signature sheet I keep in a file in my office, it contains all original signatures from the IDT. Since I am the only one (other than pharmacy) that can electronically sign this sheet I take it to our plan od care meetings and pass around to get everyones signature. I also keep a patient demos page, PT/OT/ST minutes as they provide them and if there are other printed pages not on the hard copy record, e.g. current dietary regime.
My questions are this:
1. does the 15 month rule apply to date of admit or discharge? I have been writting the date when the 15 months are up on the demo page of each patient and base it on the date of discharge. So if a patient admit in july 2011 and discharges in Sept 2011 I put the 15 month date as December 2013.
2. Am I correctly maintaining all the MDS info?
Nov 7, '11
RAI Manual, pg 2-6: "The Federal regulatory requirement at 42 CFR 483.20(d) requires nursing homes to maintain all resident assessments completed within the previous 15 months in the resident's active clinical record."
It is based on the Z0500B and type of each individual assessment, not admission or discharge. The active clinical record must contain the "demographic information (Items A0500-A1600) from the most recent admission assessment" and any assessments with a Z0500B date in the last 15 months.
It is safe to wait until the discharge date to move all information out of the active clinical record. However, if the resident stays longer than 15 months then you can begin moving the oldest MDS records out of the active clinical file except for the most recent admission demographic info.