MDS 3.0 & RAP---new CMS guideline on printing MDS's - page 2

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... Read More

  1. by   crazyforthis
    Hello, I am brand NEW to MDS and to the skilled nursing facility I am now employed at. I have been an RN for many years but always in acute care and more recently in telephonic disease management, until now. I will be taking an MDS bootcamp training in May 2011 but for now am being trained by the current MDS person who is retiring in June 2011. She has been doing MDS for 3 years and is very difficult to learn from as she has a hard time explaining anything. Her answer is frequently 'because that is the way they did it when I came'. Not trying to diss her, she was the one there for all the 2.0 to 3.0 transitions I have heard about and I can't imagine what a nightmare that was. I do have some questions though... It is a 49 bed SNF, Medicare only (not Medicaid certified) and she is the only MDS person there and is way behind on alot of the assessments etc. I can understand why! I am confused about a couple things she has not been able to explain as yet. 1. Is it required to keep printed (hard copies) of every MDS entry, assessment, modification discharge etc on the patients hard copy record? We have mostly electronic patient records currently but also have a hard copy record for a few things not (yet) managed in the electronic record. We use VisatKeane for our MDS application which is seperate from the electronic patient record. When we complete an assessment for instance a 14 day, we can still view it in our MDS app even after it has been submitted to CMS, but we also print the entire assessment and then also copy the section A and Z additionally. We have original signatures from different modalities i.e. PT/OT/ST/RT/SW etc. We attach the original signature sheet to the extra copy of section A and this is kept in the MDS office. The full printed assessment and a copy of the original signature section Z is put on the patients hard copy record at the nurses station. This is done for every MDS entry we do. When the patient discharges we add the discharge assessment to it and it all goes to med records. When we submit our completed assessments to CMS we download the batch file to a CD which is also kept (forever?). The DON has asked if we are required by CMS/State anyone to make all the copies and keep them all. The retiring MDS person there says yes because we have to have a paper copy available in case the computer 'goes down'. My thought is that these MDS files are saved on a disk and the application we use is on several computers and if the computers all go down they will be back up eventually and we will still be able to access the MDS files completed there when the computer does come back up, right? I just do not understand why all the paper? Being so new to MDS the answer may be an obvious YES but I would like to hear from anyone and everyone else about this... seriously do we need all these paper copies? Thank you all so much!
  2. by   rukiddingme
    From what I understand:
    In order to have electronic records ONLY, you're software must be set-up for electronic signatures, so each team member can 'electronically sign' for each MDS you complete. Your records must also be available to floor staff - to view care plans,etc. as needed, unless you would continue to print these out and keep in the chart or wherever.

    At my facility, we do not have electronic signature capability, so we print out everything. We have set-up our printer to print 2 pages on each side of the paper, so it has cut down on pages dramatically.
  3. by   crazyforthis
    Thank you rukiddingme! This makes much more sense now. And gives me new thoughts to discuss with my DON!
  4. by   Talino
    just to clarify...

    If your MDS is (1) maintained electronically and readily accessible to staff, surveyors, and/or other authorized agencies, but (2) you do not have the capacity for electronic signatures, you are only required to print the signed/dated hard copies of:
    • CAA completion items V0200B-C (if a full comprehensive MDS)
    • Correction completion items X1100A-E (if this a Correction Request), and
    • Assessment Administration items Z0400-Z0500 (signatures of those completing the assm't)

    There is no need to have a printed hard copy of the entire MDS assm't. (see also RAI p2-6)
  5. by   Magaly63
    Quote from rukiddingme
    From what I understand:
    In order to have electronic records ONLY, you're software must be set-up for electronic signatures, so each team member can 'electronically sign' for each MDS you complete. Your records must also be available to floor staff - to view care plans,etc. as needed, unless you would continue to print these out and keep in the chart or wherever.

    At my facility, we do not have electronic signature capability, so we print out everything. We have set-up our printer to print 2 pages on each side of the paper, so it has cut down on pages dramatically.

    Actually, if your printer allows it in "properties", you can print 4 pages on each side of the paper.
    That's what we do....it's a little on the small side, but doable, and even better for the sake of space and storage.

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