Who Can Do MDS Assessments?
Updated: Aug 14
Some online websites have WRONG information about who can do MDSs. A BSN degree is NOT required to do MDSs. There are many awesome, expert lead MDS nurses who are LVNs/LPNs! One does NOT have to be MDS certified to start doing MDSs. Licensed nurses are NOT the only ones that can input MDS data! Talk to your facility's MDS coordinator or MDS nurse and you can confirm all this. Better yet, read on. Find out below what the actual regulation says...
The RAI (Resident Assessment Instrument) consists of the MDS (Minimum Data Set) and the CAA (Care Area Assessment). Members of the IDT (Interdisciplinary Team) are usually assigned to answer certain sections of the MDS and the CAA portions, depending on the facility's policy and procedure and depending on the job descriptions. These IDT members who know how to answer (or code) the MDS can input data in the MDS: Social Service Designee, Dietary Supervisor/Designee, Therapists, Activity Directors or Assistants, CNAs, DON, Administrator, LVNs and RNs. These IDT members may fill in the CAA as well. Therapists (PT/OT/ST) who are not in-house usually do not sign the MDS but provide answers to sections pertaining therapy treatments. The Business Office and/or Admission Department input resident demographics into the facility's software that sometimes automatically transfers into the MDS program. An RN must then sign the MDS as complete when all the sections are completed.
Want a simple answer? IDT members can answer sections of the MDS and an RN must certify the MDS as complete.
Want the not-so-simplified, legal, long-form answer verbatim? Below in blue are the regulations regarding completion of the MDS from pages 1-7 and 1-8 of the MDS manual, also known as the RAI manual currently called Center for Medicare and Medicaid Services Long Term Care Resident Assessment Instrument 3.0 User's Manual version 1.14:
The RAI process Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that
(1) the assessment accurately reflects the resident’s status
(2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals
(3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.
Nursing homes are left to determine
(1) who should participate in the assessment process
(2) how the assessment process is completed
(3) how the assessment information is documented while remaining in compliance with the requirements of the Federal regulations and the instructions contained within the manual.
Given the requirements of participation of appropriate health professionals and direct care staff, completion of the RAI is best accomplished by an interdisciplinary team (IDT) that includes nursing home staff with varied clinical backgrounds, including nursing staff and the resident’s physician. Such a team brings their combined experience and knowledge to the table in providing an understanding of the strengths, needs and preferences of a resident to ensure the best possible quality of care and quality of life.
Update: Before writing this article, I had contacted a few of those websites to correct their information. After no replies and not seeing any changes from those sites, I decided to share the actual regulation in this article. (The pages remain the same on the current RAI manual version 1.15.) As of 11/02/2017, some of those "learn" or "study" dot coms or dot orgs have finally edited the information on their articles. Some but not all.
Other related article: What is an MDS nurse?
Interested in learning MDS through a formal MDS Training? Visit www.mdsadvisor.org