Problems with MDS submission in NY

[meghan61]

I work in a New York facility and have been completing MDS since the inception.

It is a 300 bed RHCF.The woman that does the actual submission is a secretary who was trained by the former Medical Records person. I have had problems with her changing my data.

She has administrative privileges and I do not.

When I do the next assessment, I am finding that some data was changed.

I notified our department head but nothing has been done.

When I confront her she denies it or doesn't answer me or says it must have been someone else.

She refuses to attend any MDS seminars. Any suggestions?

I am very concerned because we are going to get nailed on RAC audits.

She changes rehab minutes, adds IV meds, Oxygen, chemo, without the profesionals knowledge or having them re-sign.

[Talino]

If you complete MDSs directly into the computer, considering everyone who has access is assigned a unique ID, there is a feature (can be software-specific) to view the "details" of each assessment - who did what and what date. If you completed your section on July 15 and someone went in to that same section and changed an entry, his/her ID and the exact date will be posted in the "details". The feature, however, may have only been granted to those w/ adm. rights.

An advantage of e-MDS - you cannot be held accountable for an entry that has been altered by someone else after you signed and dated the completion of your section. At least you know where to look to get vindicated. But beware, those w/ adm. rights may likely know your unique IDs and can login as you.

Your best bet, review your policy on corporate compliance. See what rights or protection are afforded to individual computer users. If you believe yours were violated you can have the assm'ts in question reviewed. The software vendor can even assist.