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Q: In our facility, we handwrite the MDS, sign it, and then key the assessment information into the computer. We then place the handwritten copy of the MDS in the resident's chart, but we don't print the computer copy. Is this acceptable?

Julia's PPS Chat, May 26, 2004

Welcome once again to our PPS chat!

Some of you might remember when a computer was a huge machine that filled up a room, and was only used by professors and students of computer science. How times have changed! Now, we all use computers to complete the MDS.

But what should you do if you don't print out the computer copy of the MDS? Continue reading for the answer.

Q: In our facility, we handwrite the MDS, sign it, and then key the assessment information into the computer. We then place the handwritten copy of the MDS in the resident's chart, but we don't print the computer copy. Is this acceptable?

A: Yes, this is allowed. As long as the handwritten MDS in the chart correctly matches the computer copy, you only need to keep one copy in the medical record.

CMS explains this issue on p. 1-27 of the revised Resident Assessment Instrument User's Manual. It states, "There is no requirement to maintain two copies of the form in the resident's record (the handwritten and computer-generated MDS). Either a handwritten or a computer-generated form is equally acceptable."

Keep 15 months of MDS data in a resident's clinical record in a location that is accessible to all professional staff. Don't let these 15 months of data get locked away in the medical records department. Staff should have access to this assessment information in order to provide proper care for the resident.

Therefore, either your computer-generated or your handwritten form can be placed in the resident's chart. Just be sure you have one of the two forms readily available.

We'll be chatting again soon-