MDS 3.0 & RAP---new CMS guideline on printing MDS's

Specialties MDS

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Specializes in Long Term Care.

Greetings to all...new to site...I am an MDS Coordinator for an 88 bed facility. Have been doing MDS here since 2003 so I am quite familiar with the process...6 years in this office.

Have many of you read the specs on the MDS 3.0? I have downloaded the form from many different sites and from what I can gather, there will be no RAP on the 3.0. Am I correct in this? :yeah:

Second, did I read the new guidelines from CMS correct in that if your MDS is maintained electronically you no longer have to print them and put them on the chart after June 17, 2009? 15 months worth of MDS information in one chart takes a lot of space in the record, is costly for the facility (paper and toner), requires filing time, and is not "envirnomentally friendly" because of all of the paper required to do this. :yeah::yeah:

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Specializes in LTC, Hospice, Case Management.
Greetings to all...new to site...I am an MDS Coordinator for an 88 bed facility. Have been doing MDS here since 2003 so I am quite familiar with the process...6 years in this office.

Have many of you read the specs on the MDS 3.0? I have downloaded the form from many different sites and from what I can gather, there will be no RAP on the 3.0. Am I correct in this? :yeah:

Second, did I read the new guidelines from CMS correct in that if your MDS is maintained electronically you no longer have to print them and put them on the chart after June 17, 2009? 15 months worth of MDS information in one chart takes a lot of space in the record, is costly for the facility (paper and toner), requires filing time, and is not "envirnomentally friendly" because of all of the paper required to do this. :yeah::yeah:

Have not heard of this printing rule. Can you please cite your source for this information.

Talino.. are you around - you've always got the answers to stuff like this??

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Specializes in Long Term Care.

Thank you for responding so quickly. I am new to this site and for some odd reason finding myself praying that someone else reads this and tells me I am not entirely mistaken....

CMS Reference S&C-09-22

Cover page...

5th bullet, "Deleted guidance requiring paper copy storage of Minimum Data Set (MDS) in nursing homes with electronic records at Tag F286, 483.20(d), Use; and"

Then ...page 4 says...

R Appendix PP, TagF286, Use - deleted a sentence requiring storage of paper copies of assessments in facilities with electronic records"

Then I read it one more time on page 95 "Deletion of sentence at F286 (MDS Use) requiring storage of paper copy of MDS for homes using all electronic records. This is no longer required for these homes.

Instructor's notes:

The following sentence is being deleted: "Whether or not the facility's clinical record system is entirely electronic, a hard copy of all MDS forms, including the signatures of the facility staff attesting to the accuracy and completion of the records, must be maintained in the resident's clinical record."

Maintaining 15 months of MDS data is still required. This deletion simply removes the "hard copy" language for homes using electronic records. The MDS records must still be accessible to clinical staff, the State, and CMS, as stated by current language that remains at this Tag."

Someone please tell me that I am reading this correctly....pah pah pah pleeaaasseeee!!

This is actually what led me to your site. I wanted someone besides me to say, "Yep, that is exactly what it means"...

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Specializes in ER CCU MICU SICU LTC/SNF.

nascar, i am assuming santee is referring to this memo back in january '09. (see last page)

at one point there was a conflict between the som appendix pp instructions and the rai manual regarding keeping both electronic and hardcopies of mds which was discussed here

yes, after 4 years, it has been clarified. this is affirming, effective 4/10/09, if a facility completes their mds directly into the computer (electronically) there is no need to print a hardcopy of that mds and keep it in the active chart for 15 months. the electronic mds stored in the computer must still adhere to the requirement to be accessible to staff and surveyors.

this may not apply to facilities who complete mds in hardcopies only then enters them in a computer since the signature is not entered electronically. the hardcopies still need to be retained in the active chart for 15 months.

updated appendix pp of the som see pp 119-120

regarding the mds 3.0, i would wait 'til the final specs are out in october '09. this is the most recent draft of mds 3.0, which cms does not recommend to be used for training.

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Specializes in Long Term Care.

soo...even transmittal 41 released on 04/10/2009 gives us the option to store the records in the manner the facility chooses and NOT be required to maintain "hard copies" on the charts....

Correct?

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Specializes in ER CCU MICU SICU LTC/SNF.

the guideline says...

"the requirement to maintain 15 months of data in the resident's active clinical record applies regardless of form of storage to all mds forms..."

as long as ...

"the information must be kept in a centralized location, accessible to all professional staff members (including consultants) who need to review the information in order to provide care to the resident."

the "active clinical record" does not solely pertain to the existing patient's chart in a binder. the mds that is computerized (a form of storage) and easily accessed is also an active clinical record. therefore, you do not need to have a printed mds in the chart.

an overflow folder (another form of storage) that is kept within a unit that is easily retrieved is also a part of an active clinical record. hence, a facility who has no computerized mds storage capabilities can maintain their original hardcopies in that overflow folder rather than in the actual working chart.

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Specializes in Long Term Care.

Oh my....I could kiss you...that is exactly as I was hoping it was interpreted...we have networked computers all over this facility...with access to the eChart at each station. And...it contains well more than 15 months worth of MDS information...it has all of them in it without regard to date...

YOU are mahvelous...

Thanks so very much....I have recommended your site to our DON and ADON as well...we really did not know you guys even existed. Nice to see a site for nurses by nurses!!

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Specializes in LTC, Hospice, Case Management.
Oh my....I could kiss you...that is exactly as I was hoping it was interpreted...we have networked computers all over this facility...with access to the eChart at each station. And...it contains well more than 15 months worth of MDS information...it has all of them in it without regard to date...

YOU are mahvelous...

Thanks so very much....I have recommended your site to our DON and ADON as well...we really did not know you guys even existed. Nice to see a site for nurses by nurses!!

I think I know quite a lot about MDS's and am always glad to share my knowledge but, Talino is the absolute gu-ru as to where to find all the "rules".

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Specializes in Long Term Care.

Thank you both so very much. It's always nice when CMS offers a tiny bit to make our lives easier. I am heading to the Medicare BootCampin Atlanta Georgia tomorrow for four days put on by HCPro...will take great notes and share if anything sticks out in my mind when I return. Sometimes it's stuff we should already know, others it is really good information.

Again, thank you both so much!! I am certainly glad to have found this website.

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Specializes in Long Term Care.

Just returned from HCPro's Medicare Bootcamp for Long Term Care in Atlanta. Dissapointingly, yes, the MDS 3.0 will contain a "RAPS" section which will be referred to as the "CATS" now. Can't remember exactly what he said it will stand for, but it will basically be the same thing. I believe my resources at my software vendor, American HealthTech, have stated that electronic signatures will be a required portion of the new MDS 3.0. This information I would verify if my facility was not capable of electronic signatures, however, if it is indeed a requirement then my facility and the software we are using must be modified to permit us to do such a thing. Once accomplished, we will no longer be required to print hard copy MDS for any resident chart.

I highly recommend this 4 day seminar on Medicare. It was extremely helpful. So much valuable information I could not even begin to put it all on one post. ALL MDS and Billers need to attend this training. It could literally make thousands of dollars difference in the way you approach your medicare.

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Hi--

  1. CAT= Care Area Trigger
  2. Re: Electronic signature requirement for MDS 3.0

  • There is no electronic signature requirement attached to MDS 3.0. Many facilities will still use a "hard-copy" MDS, physically sign the paper MDS, and employ software only to data entry for mandatory submission to CMS.
  • IF a facility has a complete Electronic Health Record, or uses software to data enter, complete, and maintain MDS data with NO paper output, then the software must meet certain security requirements.
  • These security policies must include assignment of a login to one particular person, regular/routine password changes, and many other privacy/security safeguards, to assure valid electronic signatures.

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