Changing MDS Data

[meghan61]

Hi,

We currently have a MDS coordinator that changes data on the completed MDS form during the care plan meeting. I have 2 concerns with this process. First, she does not verify the data, if one discipline tells her that a resident doesn't use bedrails for positioning, she will change it. Now I completed the MDS and the resident had an order for the siderails and they were in use. Then she will have the data entry person make the changes to the MDS software-so she is not signing for the changes that were made. Essentially she is changing data that other people are signing for. Anyone care to comment?

Thank you.

[Shortcake123]

Is this the printed MDS that has been signed after submission? If it is it cannot be changed, but like you I am new to this as well. You cannot make changes to a submitted MDS unless you make a modification to a prior submission. Can someone else possibly help us out? Thanks.

Doris

[meghan61]

Thanks for your comment. I started doing MDS in 1990, but I changed careers from 2007-2009 and then returned. Most of these MDS are prior to submission. My concern is that she is changing data that other people have signed for, which could constitute fraud.

Typically when I would meet with the team, we would all review the MDS for accuracy; if changes are needed, I or the designated person would have the MDS opened, make the change and E-sign. This way we also had data for MDS accuracy QI. The team is concerned because she is randomly changing data without verifying it's accuracy. I have called a few other facilities in the NY area to ask but no one has returned my calls.

[Talino]

accdg. to the rai p5-6 ...

errors identified during the encoding period

to make revisions to the paper copy, enter the correct response, draw a line through the previous response without obliterating it, and initial and date the corrected entry. this procedure is similar to how an entry in the medical record is corrected.

when the data is encoded into the facility's mds system, the facility is responsible for verifying that all responses in the computer file match the responses on the paper form.

everyone is bound to this requirement. it is only prudent to inform the discipline who made the original (erroneous?) entry since he/she might have documented it or collected the info somewhere in the medical record. proper communication will also avert making the same mistake or set right misinterpretations in coding.

[susanthomas1954]

Don't forget that the nurse who signs the R line is just saying that the MDS was completed under his/her oversight. There are several ways to look at your situation. I have some social service people who are not well trained in the MDS process, and I FREQUENTLY have to correct their answers. I usually make a list of my corrections and let them know what I have done, prior to the entry on the electronic MDS.

I would ask non-threatening questions, if I were you. I would ask "Can you explain that change to me?" really humbly, if I were you. You may find out some things that are in the manual that you should know already, or she may find out that you know more than she thinks. The best thing here is to ask the questions, and if the person you are asking gets defensive, humble down and explain that you are asking because you want to do the job right and you just don't understand.

It took me a lot of arrogant years to find out that people feel threatened by questions, so I really had to watch a lot of Columbo reruns to get the technique down. I've actually come to like acting dumb now, and I get a lot more education accomplished with humility than I ever did with arrogance or even neutrality.....

ST