inappropriately unlocked record, now what?

[crazyforthis]

Hello everyone!

I need help with this one... have looked in RAI manual but this is not addressed unless I just missed it. A staff member here where I work was trying to help me but inputting some date into MDS. We have a patient that was admitted and discharged a couple days later back to hospital and then readmitted to us several days later. She was not paying attention to the dates involved and unlocked a record that had already been sent to and accepted by CMS on the patients first admit. She did this to change an answer in the Section B about if the patient was wearing glasses during assessment. I am not sure why she thought it was okay. So now, do I just run the audit on it again and resend to CMS or do I do a Modification? It did not need to be changed so if I do a Modification do I say it was inadvertantly unlocked or? Sometimes help is more work, I know she meant well but this was over stepping her boundaries and I will be coaching her about it.... Any help appreciated as I am still learning it all myself.

[Talino]

If it's unlocked and altered that's only in your system. Although, it can be software-specific, I don't think you can save the change/s that was made of an already submitted MDS in your system, unless you actually selected the Correction option or copy option. Try closing the program and see if it's still "unlocked." You may need to call the vendor to undo it. Nonetheless, it does not affect the MDS that was already received in the QIES.

[andy3k]

To add to Talino's answer, it is important that the data in your MDS data entry software match the data that was originally submitted to CMS.

1. If you ever need to do a modification in the future, you want to start with the original data. Otherwise, you might run into problems with Section X prior fields filling improperly. You might also inadvertently send whatever incorrect data was entered into the edited record.

2. Depending on your state, surveyors might tag you for having different information in the MDS software than on paper or in the CMS database. They have done that in my state.

[crazyforthis]

Hi Andy and Talino,

Thank you for your help. Andy I AM in your state I believe, I am in Texas. The program we use for MDS is called VistaKeane or Keane Care. It does allow us to unlock records and change in after having already submitted and accepted by CMS. Here is what I did, I probably made it worse...

1. I went to my DON to explain the situation as best as I understood it

2. I again discussed the issue with the person that "unlocked" the record to clarify again what she changed.

3. Since the record was still unlocked I corrected it back to what the original one had, then ran the audit with locked it again.

4. When I sent my EDS file to CMS on Friday evening this record was included.

4. CMS rejected it as a duplicate record.

5. DO I need to do a modification now?

NOW... do I need to do anything else? Have I made it worse? The relocked record should now be identical to the initial locked one...

We do not have paper co[pies here except of the Section V which goes into our patients current hard copy record. We do have and keep the orioginal hardcopy of the IDT signatures. Our Nurses have almost 100% electronic patient charting, and of course our MDS program is all electronic except for the IDT sign sheet. Is this okay? I was told several months back that we did not need to print or maintain other paper records for MDS since we do it electronically. Even what little hard copy we have gets scanned into an electronic program after patient discharges.

[andy3k]

The rejection of the duplicate record is expected and good. A modification is not necessary. As long as the software version matches the CMS version, you are done.

With regards to electronic vs paper records, reference the article "Maintenance of 15 Months of MDS" in the December 2010 issue of The MDS Mentor for an explanation of that issue.