Long-Term Care Survey Alert

Question: I have several residents whose charts are exploding. Is it really necessary for me to keep all 15 months of assessments in the current chart?

Answer: According to the RAI manual, all demographic information must remain in the most recent clinical record. In many instances, the 15 months of assessments are stored on the nursing unit, easily accessible but not necessarily in the clinical record.

Also, on pages 2-6 of the RAI manual, you’ll find several notations regarding the electronic maintenance of the MDS. First, nursing homes have the option for clinical records to be maintained electronically rather than in a hard copy. This requirement applies to the MDS, as well as the entire MDS assessment. In other words, if the MDS is accessible electronically, then you don’t have to print the entire MDS assessment to be maintained as a hard copy in the clinical record.

Where the MDS is maintained electronically without the use of electronic signatures, the items that you must maintain at a minimum on a hard copy are:

the signed and dated CAAs,

correction completions, and

assessment completion data that identifies the resident.

Those are sections Z0200 B-C, X 1100 A-E, and Z0400-Z0500.