MDS Alert

See how different facilities across the country assign different sections of the MDS and find tips for helping your colleagues help you.

The minimum data set (MDS) is a whopper of a document and tool, and just looking at the thing as a whole can be overwhelming. Realizing just how many sections comprise it — and how much information one needs to complete the MDS accurately and comprehensively, not to mention submit it on time — is daunting.

Context: The RAI Manual does not specify which staff members or departments are responsible for completing specific sections of the MDS. In Chapter 1 - 7, the RAI Manual states: “The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20(b)(1)(xviii), (g), and (h) require that: (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals and nursing homes are left to determine (1) who should participate in the assessment process.”

Ideally, an interdisciplinary team (IDT) is involved in assessing and care planning for each individual, a collaboration that may or may not be reflected in your facility’s determination of who completes which section of the MDS.

Beware: The MDS software that your facility uses may affect who is able to complete a particular section. For this reason, some MDS coordinators or NACs may have sole access to the software and therefore find that they have to interview their colleagues for the information necessary to complete a section.

Additionally, your state may have specific requirements for who should complete particular sections of the MDS, especially for Section S, if your state requires that section.

Remember: The MDS coordinator or NAC is usually the person who ultimately signs off on the accuracy and completion of the MDS, as well as taking on the responsibility of submitting it.

Take a Peek: Who Does What Elsewhere

You may wonder whether MDS coordinators or nurse assessment coordinators (NACs) are solely responsible for the completion and submission of the MDS or how other facilities utilize the different roles and expertise of various staff. Here’s a breakdown of who completes which section, from a random, self-selected sample of staff from facilities across the country:

Section A: MDS coordinator, Social Services
Section B: MDS coordinator, Social Services, Activities, Nursing
Section C: MDS coordinator, Social Services, Nursing
Section D: MDS coordinator, Social Services
Section E: MDS coordinator, Social Services
Section F: Activities
Section G: MDS coordinator, CNA documentation for ADLs
Section GG: Therapy, Restorative Nursing, MDS
Section H: MDS coordinator
Section I: MDS coordinator
Section J: MDS coordinator, Dietary Services
Section K: MDS coordinator, Dietary Services
Section L: MDS coordinator, Dietary Services
Section M: MDS coordinator, Wound Nurse
Section N: MDS coordinator
Section O: MDS coordinator (frequently with therapy signoff)
Section P: MDS coordinator, Social Services
Section Q: MDS coordinator, Social Services
Section S (different for every state): MDS coordinator, Nursing, Social Services
Section V: MDS coordinator
Section X: MDS coordinator

Some facilities find that certain staff members are crucial for completing particular parts of MDS sections. These subsections stood out, in that they sometimes require a special touch, and multiple departments or staff collaborate to complete the section at large:

BIMs: Social services, MDS, Occupational Therapy, Speech Therapy
Mood: Social Services, MDS
Pain: RN, MDS, Unit Manager, Charge Nurse

Craft Facility Policy for Support

If you’re finding that you’re hunting down colleagues in desperation before the MDS submission deadline, there are options. As the MDS coordinator or NAC, you are intimately aware of the significance of the MDS, particularly when it comes to facility reimbursement. Though you understand that your colleagues’ paychecks also depend on the accurate, timely, and successful submission of this document, you may have trouble emphasizing how much their help helps you.

Education may be your best bet, especially if you’re working with colleagues who are new to your facility or to the RAI process. While you may not feel like you have time to conduct formal or informal trainings on the significance of the MDS and a colleague’s role in completing it, doing so could save you a lot of angst. Plus, others can’t help you if they don’t understand what help you need.

If you have some departments who are consistently not pulling their weight — or meeting the deadlines you require — go to your higher-ups, especially in administration.

Don’t make it personal by blaming an individual staff member, but ask for help in officially delineating which departments or roles are crucial in filling out the MDS. Adjusting your facility’s policies to put those responsibilities down on paper can go a long way in setting out and emphasizing various departments’ accountability. See whether your human resources department can help you by updating the job descriptions for those respective roles, too, so everyone is on board with MDS responsibilities from the get-go — and long-term staff understand that helping with the MDS really is part of the job!