Select Page

An MDS nurse is the driving force behind electronic nursing documentation in nursing home software. That is why he or she will need to be both knowledgeable and thorough in their processes. At the same time, the MDS nurse cannot do everything. Rather, he or she will need to keep the rest of the staff on their toes in order to get the documentation that must be entered into a long term care software system. That includes instructing them on how to get the information needed, asking them to be extra vigilant and report anything they think is noteworthy, and identifying where they have made errors and subsequently holding them accountable. 

Electronic nursing documentation helps keep track of ADL assistance.
An MDS nurse is on top of the ADL function of residents.

The Role of the MDS Nurse in Training 

The MDS nurse will often be responsible for training CNAs on documentation. This should be done consistently, with repeated inservice meetings led by the MDS nurse held every two to three months to ensure that CNAs know what needs to be included in electronic nursing documentation.

The point of emphasis in training should be ADL function. Many CNAs underestimate the amount of care being provided on a daily basis. They often do not realize that the moment they have to help stabilize a resident or assist them physically, they are providing a higher level of care. 

Example: Contact guard or minimal assistance, like a hand placed on a shoulder during an activity, can mean a higher level of care if the resident requires stand-by assistance or supervision. Similarly, your staff may downgrade a resident to a lower level of care prematurely, not understanding that just one incident of a higher level of care is sufficient for a resident to be documented as such. 

How an MDS Coordinator Can Make Staff More Aware

A good MDS nurse will establish a system in which CNAs report anything that cannot be documented but may be worth investigating. Some observations—like a resident clearing his or her throat, coughing while eating, or a dysphagia episode—may turn out to be nothing. But they may also be issues that require extra care. That is why the MDS coordinator must encourage his or her team to supply any and every bit of information that may be relevant to electronic nursing documentation. 

Establishing a stop-and-watch means getting CNAs to communicate what they see and thinking more like investigators. Anything that is suspicious, but cannot officially be charted in electronic nursing documentation software, will then be relayed to a floor nurse. They can fill out note cards that hang on the wall, in what is similar to a suggestion box and hand those directly to a nurse. The MDS nurse can then take these into consideration as he or she puts together various clues to prepare potential investigations as learned during MDS nurse training. For more about Minimum Data Sets and frequency reports, read here

Contact us here if you would like to test drive our user-friendly long term care software.

The Importance of Audits in Electronic Nursing Documentation 

The MDS nurse’s job is directly related to charting, which means he or she depends on CNAs for proper electronic nursing documentation in a long term care software system. While the MDS nurse does not have authority over CNAs, he or she can still review their charting and hold inservice meetings to set expectations. The majority of an MDS nurse’s job is getting information from other members of the team at the facility. 

The MDS nurse will act as an auditor and work alongside the DON to ensure that CNAs pull their weight on documentation. If they are falling short, the MDS nurse will be the one to inservice them or write them up. Before any inservice, though, the MDS nurse must conduct an audit to locate the CNAs who are causing issues with documentation. It is often just a few individuals who depart from protocol. The MDS nurse must be willing to investigate these matters and confront those CNAs. 

nurse talking to doctors
Electronic nursing documentation is a team effort headed by the MDS nurse.

During the audit process, the MDS nurse will look at ADL charting and compare what was documented by the day shift to what was documented by the night shift or compare what was documented on one day to that which was documented on another to find inconsistencies

Every 90 days, an MDS nurse must look back at a resident’s history and be proactive in searching for inconsistencies among their functional dependencies. If a resident all of sudden stopped requiring assistance on day 20 of the period reviewed, that is a sign that something may be wrong in documentation. It is unlikely that a resident goes from needing assistance to becoming fully independent, as such an individual would not belong in a skilled nursing facility. 

If there is a sudden shift in functionality, the MDS nurse must find the point that it started as well as the cause. In most cases, the cause is parrot charting: one nurse charted a resident a certain way, and this influenced how the others perceived him or her, resulting in the same mistake being repeated for days or weeks. 

For more on recent trends in long term care, read our blog and subscribe to the LTC Heroes podcast