Signing Assessments, is this wrong?

  1. In our facility, the SSD, Activities, Dietary and Therapy give me there sections on paper, they have the resident name, assessment type and ARD on their sections. I key it in and complete the MDS. The R2b date is the day that it is keyed into the computer and complete. I sign off on the sections that I do and date the same as the R2b, the other IDT's sign off on their sections and date same R2b but sometimes they are not signing it that day, is this considered back dating? If so, should they be signing the actual date they review it? I shred the info they give me once it is signed off by them. Also the RN never dates after she signs because the R2b date is already printed where she signs. Is this correct?
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    About mdsmadness

    Joined: Jul '08; Posts: 21; Likes: 11

    12 Comments

  3. by   Talino
    If signed today, today's date should be in it. Otherwise, it is backdating. If it cannot be signed on the date it is completed, it is appropriate to use the actual date that it is signed. Document the reason for discrepancy.

    If the R2B date is already printed, the RN's signature should be entered on that same date.

    A facility P&P for such practice should be in place.
  4. by   mdsmadness
    What is a P&P?
  5. by   MuseAcal
    P&P is shorthand for "Policy and Procedures" - your Nursing Services Director should have a copy and there should be a copy accessable by the charge nurses (and you!) at all times as well.
  6. by   Nascar nurse
    From my experience with a couple different MDS software programs, you should be able to print out the MDS prior to typing in the R2b date. Once printed, then go back in and add the actual R2b date used before transmitting.
  7. by   mdsmadness
    My software gives me an error if the R2b date is not filled is prior to sealing it.......so that means that I have to type it in when I am done completing it, but sometimes I stay late after all IDT's are gone. Does that mean that I should have them date it the day that they sign it? If they date it the same day that I type in the R2b, even though they completed their sections on paper prior to that but may not be able to sign the same day that I complete it........is that backdating? What exactly are the regs?
  8. by   Talino
    Your practice of completing and signing the MDS on the R2B day leaves you no room for those occasions you've mentioned. To abide by regulation, it would seem the IDTs sigs will always be a discrepancy.

    See the regs in this post

    When scheduling, have the disciplines complete their MDS sections no later than 2 days prior to the actual R2B date. If the R2B is 7/25/08, complete the MDS today (7/23) and enter the R2B date as 7/25/08 in order to "seal" the MDS. You may get an error edit check from your software regarding the R2B date not matching today's. Ignore it and print the MDS. Track the disciplines for their sigs. then on 7/25 have the RN sign R2B.
  9. by   mdsmadness
    Thanks for the info Talino, actually have EDS coming tomorrow for documentation training and going to ask them also.....ahhhh, kind of leary about that but I know that come Dec or Jan, they will be back.........hopefully will get some good info on Documentation because ours really bites, conflicts everywhere!! I was always told if you do not have the documentation to back it up, don't claim it! Better to know the answers now and just move forward. Thanks again!
  10. by   OHIOGIRL08
    WE HAVE A PROBLEM THATS SIMILAR TO YOURS. WE HAVE ALWAYS GOT THE PAPER SECTIONS FROM EACH DISIPLINE AND HAVE ENTERED THE INFO INTO THE COMPUTER, WE WOULD PUT THE DATE IN RB2 USUALLY 1 -2 DAYS AFTER THE ARD, THE RN WOULD THEN LOOK IT OVER AND SIGN IT. I WOULD SIGN OFF ON THE SECTIONS I DID AND THE OTHER DISIPLINES DID THE SAME.
    NOW THE PROBLEM.......WE HAVE A WHOLE NEW COMPUTER SOFTWARE, WHEN WE PUT IN THE INFO, THE OTHER DISIPLINES NOW ENTER ALL THEIR INFO ON THEIR OWN SECTIONS AND THEN SIGN OFF. WE ERROR CHECK AFTER WE HAVE ALL OUR INFO IN AND THEN THE RN SIGNS OFF ON IT. THE PROBLEM, THE RN IS TOTALLY NEW TO MDS, ONLY 6 WEEKS IN.....SHE SIGNED OFF ON SOME MDS, THE ARD WAS 7/8/2008, SHE JUST GOT IT SIGNED OFF 7/22/2008 SO SHE LEFT THE RB2 DATE 7/22/2008 BUT THE LAST RB2 DATE WAS 4/9/2008, WHEN WE SUBMITTED WE GOT 5 WARNINGS ON 5 RESIDENTS, THE STATE DIDN'T REJECT BUT IT'S A MESS. TOO MANY FINGERS IN THE MDS.....SO NOW WE ( THE LPN ) HAVE TO GO BACK AND DOUBLE CHECK THE RB2 DATE AFTER THE RN SIGNS. BUT ON THE OTHER HAND, THAT'S BACK DATING, IS THAT LEGAL? ANYONE GOT ANY SUGGESTIONS.....ANY HELP APPRECIATED. NEW SOFTWARE IS ADL.....AND IT'S AWFUL.........:redpinkhe
  11. by   mdsmadness
    I do not think that I would like so many fingers in the pot either......but then MDS Nurses tend to be a little anal about their job, I know I am and admit it! lol Not all DON's know about MDS, maybe a little discussion with her about the importance of that R2B date would be helpful?
  12. by   edhcinc
    Hi--perhaps a review of the RAI Manual, pg. 1-24 and many items in Chapter 2, WITH ALL STAFF involved in the RAI process is in order...have fun!
  13. by   edhcinc
    Perhaps a review by all staff involved in the RAI process of RAI Manual pg. 1-24 and many parts of Chapter 2 is in order--have fun!!
  14. by   Rexie68
    i think i mentioned how we do it at my facility in another post, but i'll repeat here. i know that some disagree with it, but umr and doh have never had a problem. we date the working copy for the day we do it; our assistant enters the info into the computer when when we've all completed it; it's printed out, and then we all sign the computer copy with the date that we put on the working (or "hard") copy. the computer copy goes into the chart. we save the working copy in our office. some call this back-dating, but, again, we're only signing the computer copy for the same date that we signed the hard copy and no agency has had a problem with it. we make no bones about the fact that we do it this way, and, in fact, when umr has a question about something, i pull out the working copy to show what i might have scribbled on the side, etc. it's helped me out of a jam a few times, when i've written a little note to myself, such as "see nurses note of 07/29/08 for in depth description of wound, behavior, etc." umr also has found this helpful and sees no reason for us to stop doing it this way. i've hesitated to post this again, because others disagree, but i'm putting it out there because i'm sure there are many facilities that do it this way. you're signing the date that you did the mds....that's what we're supposed to do!!

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