Signing Assessments, is this wrong?

Specialties MDS

Published

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? :uhoh3: 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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Specializes in ER CCU MICU SICU LTC/SNF.

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.

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What is a P&P?

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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. :nurse:

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Specializes in LTC, Hospice, Case Management.

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.

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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?

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Specializes in ER CCU MICU SICU LTC/SNF.

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.

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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!

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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

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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?

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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!:cry:

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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!! :cry:

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