NH NC/NP Item sets-Am I doing them the hard way?

[ibtootie]

I've been an MDS coordinator for 6 months in a very small, hospital based facility whose average LOS is 30 days and we use JRAVEN. The previous MDS coordinator suddenly resigned, so I pretty much had to self-train with some input from the DON who admitted she wasn't sure how the RAI process worked. I was originally trained in 2.0 and taught to print out the RAVEN forms, have the different therapies fill out their assessment sections by hand, and everyone signed and dated the handwritten assessment forms and then I entered the information into RAVEN and signed the completed copy. Since the chance to 3.0, it seems very cumbersome and wasteful to print out the 38 page NC Item set and the 33 page NP sets to be passed around to the different therapies. I have asked about getting different software, but our small size doesn't justify the expense of a software package, so I'm stuck using JRAVEN. I attended the MDS 3.0 certification, but the instructor did little more than read directly from the RAI manual, and explained very little is plain English. Then the thought occurred that I may have been doing this all wrong from the beginning.

Can some of my more experienced MDS sisters give me some pointers how this should work correctly? Should the different therapies sign the completed form rather than the handwritten version? Must we actually use the 38 page NC item set, or can a facility create their own version of the assessment? I just want to make sure it is being done correctly.

[Talino]

...print out the raven forms, have the different therapies fill out their assessment sections by hand, and everyone signed and dated the handwritten assessment forms and then i entered the information into raven and signed the completed copy

do it the exact same way, except there is no need to print the completed mds after it has been entered in the computer. everyone involved signs/dates the handwritten mds after completion, including the rn coordinator who validates completion. the same mds is kept in the active record for 15 months. miskeyed info is not uncommon, therefore, the facility should have a procedure to ensure accuracy of the data entered in the computer.

must we actually use the 38 page nc item set, or can a facility create their own version of the assessment? i just want to make sure it is being done correctly.

rai p2-2 bullet #4 --

if allowed by the state, facilities may have some flexibility in form design (e.g., print type, color, shading, integrating triggers) or use a computer generated printout of the rai as long as the state can ensure that the facility's rai in the resident's record accurately and completely represents the cms-approved state's rai in accordance with 42 cfr 483.20(b). this applies to either pre-printed forms or computer generated printouts.