Creating an MDS Assessment

[charting50]

Our RN Coordinators and the Medical Record Dept are having a disagreement as to who is responsible and when in "creating an MDS assessment". Each discipline at our facility enters their own sections of the MDS directly into the computer. Medical Records feels that the RN Coordinator should create the assessment prior to entering their sections and the RN Coordinators feel that Medical Records should create the assessment as the other disciplines do their sections prior to the RN Coordinator. Your input as to how your facility accomplishes this would be appreciated. Also, how far in advance can the MDS assessment be created?

[Cheesecakelady]

Our RN Coordinators and the Medical Record Dept are having a disagreement as to who is responsible and when in "creating an MDS assessment". Each discipline at our facility enters their own sections of the MDS directly into the computer. Medical Records feels that the RN Coordinator should create the assessment prior to entering their sections and the RN Coordinators feel that Medical Records should create the assessment as the other disciplines do their sections prior to the RN Coordinator. Your input as to how your facility accomplishes this would be appreciated. Also, how far in advance can the MDS assessment be created?

What do you mean by "creating the MDS assessment?" You surely don't mean for Medical Records to assess the patient, do you?

[Cheesecakelady]

Deleted duplicate.

[charting50]

NO - maybe I am not using the right term - what I mean is, prior to inputting an assessment, someone has to go into the computer and "create an assessment" so that the IDT can enter their responses in their sections in the MDS. For example, after the last assessment has been entered, locked and transmitted then another assessment has to be "created" or maybe prepared or set up so that the team can start working on the next assessment.

[Bella'sMyBaby]

In my building, Medical Records enters patient demographics (birthdate, SS number, Insurance info ,etc.) as patients enter into the building.

The MDS Dept then opens up assessments (Admissions, Annuals, Quarterlies, 5, 14, 30 Day Assessments, etc.)

The Medical Record Dept is independent of our MDS Dept; they would have no way of knowing what type of Assessment is due when.

[SitcomNurse, BSN, MSN, EdD, RN]

In our facility the MDS coordinator initiates the assessment, she is the one who is certified in MDS's.

The med records person is not. Who better to work with the team in coordinating the therapy schedules and be sure to get the best capture? Think the Med Records person knows that?

MDS certified RN is also the one who helps to determine when the next is due, when there is an appropriate sig change, when there is a question of should I or shouldnt I, the MDS coordinator is who I turn to, and I TEACH the MDS.

There are constant changes in submission requirements and information requirements. I kieep up on it because I teach it, she keeps up on it because she is the one who issues the MDS schedule.

[PsychNurseWannaBe, BSN, RN]

I open, keep the team on track. I audit, rug and close. If sig change, I change assessment. Other disciplines do not have the ability to "start" or to "submit" an MDS. They can only continue or view. They also do not have access to change assessments, etc. I also send out emails to help them with CAA/CP. Medical records really has nothing to do with it other than if I am doing a new admit and I pull up their face sheet and dxs are missing. I will ask medical records to put it in.

[susanthomas1954]

Only MDS should open the assessment in the computer, early in the look back period if possible.

[lonnieandangela]

I would like to know if there is a window where assessments have to be open. When is the earliest one can be opened and when is it too late to open one? That seems to be a question I can not get answered. Thank you to anyone who can help me with that.