Can MDS coordinators do any charting?

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Specializes in HH,LTC.

Hello everyone!

In the past our ADON(LVN) was also doing the MDS but our DON would sign them. Since I have started to do MDS, the ADON has insisted on continueing to do the Careplans. Fine with me, but I'm concerned since in the past surveys her careplans have not been " well liked" by the surveyors. Her excuse has always been that she has too much on her plate. But from what I have been reading here. She nor the DON have been doing a whole lot. They are under the impression that they(DON and ADON) are not to do any assessments(admits/readmits) on any of our residents and chart a little as possible on residents especially our medicare residents. They have been told in the past that since the ADON is doing MDS, their entries or assessments can "fluff" the payment levels. This also goes to any changes to ADLs, tx, svn tx. I have since worked a few weekends to relieve some of the RNs as charge but have been told to limit my charting to a minimum and any changes need to be charted, to have one of the lvns working to chart. Is this common practice?

I know that in order to complete the MDS, I have to do a current assessment of the resident and audit the chart to make sure I have documentation to sustain the MDS. But according to them any changes or discrepencies that I find, either I will not be able to claim, and have someone correct it at that time so that I will be able to claim it. I think that by doing this we are not claiming the maximum $$. Any suggestions will be greatly appreciated.

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Specializes in Gerontology, Med surg, Home Health.

I've not heard of a regulation that would prohibit an MDS coordinator from charting or doing care plans or whatever. In Massachusetts in MMQ land, the MMQ nurse can not do the nursing summary but as far as I know, any licensed nurse is free to write a nurses' note, a care plan, or do an assessment.

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Frankly, it sounds to me as if they are "fluffing" by lying about acuity and ADLs and don't want you messing it up.

Frankly, I'd find another position. This sounds shady.

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Hi.

Re--MDS--if you have gathered additional information to support accurate coding or to add to the evaluation of care given, you, and ONLY you, should document what YOU found out during your interview or physical assessment. If you complete a section or part of a section of the MDS, you should indicate this in section AA.

Re: working on unit--if you are "in charge", you are responsible to assure that appropriate care is given and documented. If you are aware that clinical documentation is incomplete, get advice from your immediate supervisor or DN at the time If you performed nursing actions or intervened with issues, YOU are responsible for documenting YOUR observations/actions. If your DN prohibits you from doing so, DOCUMENT correctly--it is YOUR license that you are preserving to use after you resign and notify your nursing board of the nurses' improper practices.

Since an
RN
must state that he/she has coordinated the MDS, he/she must "sign" at R2b

Care planning is another whole topic. We don't care plan for surveyors--we care plan with the resident to meet his/her care needs and goals.

Think about your license and your options very carefully--good luck.

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Care planning is another whole topic. We don't care plan for surveyors--we care plan with the resident to meet his/her care needs and goals.

Oh, I care plan for both. I have learned to write the appropriate intervention like a lawyer, thinking of any loopholes State could use to ding us should they care to -- and with NYS in the sorry fiscal state it is, they look to ding.

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Specializes in HH,LTC.
Frankly, it sounds to me as if they are "fluffing" by lying about acuity and ADLs and don't want you messing it up.

I did not say that they chart to "fluff" their entries. What I am trying to say is that they do not do ANY type of assessments- new admits/readmits, or chart on any resident that has to do with MDS information because in the past they have been told that surveyors frown on DON/ADONs doing the assessments. But my question was can I as the MDS coordinator do an entry when I do my assessment for the MDS or should a floor nurse(RN or LVN) do them? We have our floor nurses doing the monthly summaries and a corresponding head to toe assessment charting each month but they don't always address everything needed for the mds.

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Specializes in LTC, Hospice, Case Management.

There is no reg against the MDS coordinator charting.

I am a nurse, I have a license, if I am doing the MDS ASSESSMENT I have every right (and obligation) to actually assess! I would be highly offended if someone tried to tell me I was just adding fluff.

Afterall, I am signing the front of the MDS that states stuff about "under penalty of federal law..civil penalties, etc" I don't look good in orange or stripes!

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Ah. I misunderstood. Thanks.

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We should frown on surveyors who frown on nurses who practice nursing! :nurse:

Most MDS coordinators would love to teach their DN/ADN how to complete the MDS--and to "savor" the "rush" of completing 6 admission, 1 SCSA, 10 quarterlies, and 6 PPS MDS with social worker on vacation, new rehab director, and July 4 holiday...:banghead:

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Specializes in HH,LTC.
Most MDS coordinators would love to teach their DN/ADN how to complete the MDS--and to "savor" the "rush" of completing 6 admission, 1 SCSA, 10 quarterlies, and 6 PPS MDS with social worker on vacation, new rehab director, and July 4 holiday...:banghead:

That would be great to have someone take care of the mds while on break or vacation! So how do you when your social worker is on vacation? Who completes her section? We have a out of town social worker that comes to our facility once a week. She has been doing this for a few years. But I'm always concerned that she won't make it. I've been told that as an RN I can complete her section. Have any of you come across this situation?

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Specializes in ER CCU MICU SICU LTC/SNF.

accdg to the rai, p1-18 2nd paragraph...

facilities have flexibility in determining who should participate in the assessment process as long as it is accurately conducted. a facility may assign responsibility for completing the rai to a number of qualified staff members. in most cases, participants in the assessment process are licensed health professionals. it is the facility's responsibility to ensure that all participants in the assessment process have the requisite knowledge to complete an accurate and comprehensive assessment.

chin up. you possess that "requisite" to complete the social worker's section. :)

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Specializes in Assessment coordinator.

I know the mind set....I hate creating my own source documentation for the MDS, because it looks like I am the only one who sees what I see. With 2.0 I have always considered the MDS an open book test on the chart. If someone else hasn't charted something, I hate to put it on the MDS. I go to the nearest responsible person for the issue (Soc Svc for behaviors, CNA's for ADL's, nurses for wounds, etc) and start a conversation by asking, "Have you ever seen Mrs. Blah acting like this?" The answer is "Oh sure, she's done that since she got here," and then I hand them the chart and ask them to do an entry that says so. Takes five seconds, and I've got my documentation, upon which I can elaborate if I choose.

ST

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