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Contents

Add an MDS

View an MDS

Edit an MDS

Delete an MDS

Unlock an MDS

View a Finished, Submitted, or Accepted MDS

Copy an MDS

Edit CAA Guidelines

 

 

Add an MDS

Use the main menu:

New Menu: MDS (Clinical Module) > MDS

Add an MDS

Click  Add MDS .

Select the type(s) of MDS you wish to add.


Click  Next .


The Assessment Information screen displays.

Enter any applicable notes in the NOTES field.


Click  Next


The MDS Screen appears. The left column displays the various sections of the MDS.

User can navigate by selecting a specific section or by clicking on the drawer to open and close.

 

As the questions are being answered, the form will deactivate questions for which the sections do not pertain. The skip patterns have been built in to help eliminate charting errors.  To complete the MDS, simply type the answer in the box provided or hover over the answer and click with your mouse.

Once a section is complete:

Click Quick Save


  This will minimize the potential for lost data due to connectivity issues and allow you to remain in the MDS to continue working.

Click Next Section .



  Any information entered at the Point of Care kiosk or any assessment from the different disciplines can be imported into the MDS.   Using the Import Data function on the control panel.  Each section in which data is imported MUST be reviewed before saving.  Imported data will not save, if not reviewed.


 

Complete the remainder of the MDS.


 

 In Section Z:

 

Once the MDS is completed (including signatures), the following steps should be followed:

Click  Calculate RUGS in the Control Panel to the left



 

Medicare and Medicaid RUGS will display

 

 You can calculate rugs from any section, but in order to validate and lock assessment, you must be in Section Z.  The system will conduct a preliminary validation on dates and question/answer.

 

    Make sure your CAAs have been completed before you go to the next step.

 

 

 


 

Next Click  Validate .

The system will audit the MDS and let you know if there are corrections that need to be made.


If your MDS has errors, you will see a pop-up box detailing which fields need to be corrected

To quickly navigate to the errored section, click on the Question outlined in the box.

Once the appropriate corrections have been made, calculate rugs and validate again.

 

If your MDS does not have any errors:

 

Click  Finish & Lock .

 

You are now ready to create your submission file and submit to CMS for processing .

 

See instructions in the MDS 3.0 Submission section of this documentation.

 

View an MDS

Click  View next to the MDS you wish to view.

 

Click  Cancel when finished.



Edit an MDS

Click  Edit next to the MDS you wish to modify.



 

Make the necessary changes.

Click  Save .


 

Delete an MDS

 

Click  Delete next to the MDS you wish to delete.

The Remove Confirm screen displays.

Click OK



 

Unlock an MDS

Click  Unlock next to the MDS you wish to unlock

 

Make the necessary changes.

 

Click  Save .

 

 

In order to delete or unlock an MDS, you must have Delete privileges. Please see your administrator.


 

View a Finished, Submitted, or Accepted MDS

 

Select Finished , Submitted , or Accepted from the View Option drop–down list.


 


Copy an MDS

 

Click Copy next to the MDS you wish to duplicate.

 

The Copied Assessment Information screen displays.



 

Select Copied For Correction if this is a correction.

 

Enter a brief description. The description field will default to the type of assessment

 

Enter notes if desired.

 

Click Next .

 

On the Available Sections screen:

 

Select the section(s) you wish to copy (use Select All or Unselect All if you wish).


 

Click Save .

 

 

You can now complete the MDS.

 

 

Helpful Tools/Functions to aid in completing the MDS

 

  • Section A – This section will be pre-filled with the resident information from the face sheet. Review the information for accuracy and complete any unanswered items. If you select No for item A2400,  the date fields will disappear and the system will jump to Section B .
  • Section C & D – Complete the questions. Click  Add Score  and the system calculates and fills in the score. Once you have a total score, the system will collapse any field that isn't required.
  • Section I – Scroll down to the Control Panel (lower left) and click  Add Diagnosis . This displays the resident's diagnosis list. If the Send to MDS  box is checked, the system will match the ICD-10 code to the corresponding Diagnosis field from I0100 to I7900 and automatically check the appropriate box(es). If the diagnosis is missing, you click  Add and add a diagnosis. Make sure the diagnosis is checked Send to MDS . Click OK when finished.

          NOTE : Diagnosis codes for fractures will not automatically check I3900 or I4000 – these will need to be manually checked in addition to adding diagnosis code.

  • Section S – This section is state–specific and is not linked to the other sections. Select and complete this section. Open the next section.
  • Section V – Answers in Section A will determine if you see question V0100, A-F . Respond to these questions if present and complete the rest of the section. 
    • While in section V, the CAA Guideline icon will be available in the Control Panel to the left . Use this icon to complete your CAA supporting documentation
  • Section Z – To autofill the Signature , Title , Sections , and Date Complete fields, click on the ‘auto Fill (Z0400) icon .   The system completes these fields. You can change the title, section and date by typing over it. Click Sign to add your signature and the signing date.



 

MDS Icons and Functions

 

Import Data Panel

 

Select which data to import into the MDS. 


 

If you choose to import data to the MDS from Point of Care/eMAR , Assessment , or Interviews , you will still need to review each section. If you do not select and review each section, the imported data will not save to the MDS.

 

 

Resident's Info

 

Import the resident's height, weight and number of physician's orders into the appropriate fields on the MDS.

 

NOTE: If your facility utilizes BLST eMAR, you will uncheck the box for Physician Orders.  This information will come from the POC/eMAR import.

 

Select the Reference Date and click  Import.

 

Assessments

 

Select the assessment data to import into the appropriate sections of the MDS. The assessments displayed are the last completed assessments in the system.

 

Select the assessment(s) you wish to import to the MDS.

 

Show All Assessments in Range check box allows you to select multiple assessments within that time frame.  For example if you are completing the Skilled Nursing Note Assessment every shift, you will have 2-3 per day, each day in the date range selected.  You can choose to import 1 or multiple assessments.

Click Import .

 

You must still review each section in order to save the imported information.

 

Any information contained in the selected assessments will be imported into the MDS.

 

Click Save when finished.


 

Point of Care/eMAR

 

If you are using Point of Care, you are able to import that data into the appropriate sections of the MDS. The categories available to be imported are ADL , Restorative , Mood , Behavior and Continence.

 


 

ADL 

 

The Observation Start and End Dates and ADL scores are displayed. Select the date range you wish to view data for.

 

  • The MDS Rug Optimization is built–in. BlueStrata  will analyze the last  21 days of Point of Care information and automatically display the ADL Score.
  • The responses displayed are the CMS algorithms for the ADL Self performance and Assistance provided.
  • The calculations of the ADL scores for the selected time frame are displayed. This allows you to select the ARD date based on maximum payment potential.  The system is only looking at ADL information entered on the POC kiosk.  It does not include ADL information entered on any nursing assessments.
  • Once the Observation Start/End date is selected, click the arrow in the first column to display ADL data for that date range.





 

Restorative Data

 

Select the Restorative Nursing Programs drawer to display the data. The data displayed will be for the same Observation Start and End dates from the ADL selection.

 


 

Mood 

 

Click the Mood drawer. The data displayed will be for the same  Observation Start  and  End  dates from the ADL selection.

 

 

 

If you are planning to complete the Mood Section D0200 Resident Interview section, do not import the Mood responses.

 

Behavior 

Click the Behavior drawer. The data displayed will be for the same  Observation Start  and  End  dates from the ADL selection.

 

Continence

Click the Continence drawer.  The data displayed will be for the same Observation Start and End dates from the ADL selection.

Click  Import


 

You must still review each section in order to save the imported information.

 

Click  Save  when finished

 

MDS Control Panel 


 

  • Calculate Rugs – Calculate Medicare and Medicaid (if applicable) RUG Scores.
  • BIMS Score – Display the BIMS score based on the Section C responses.
  • Validate – Validate entries prior to locking and submitting assessment.
  • Finish & Lock – Lock assessment and generate submission file.
  • Copy MDS – Copy the MDS into a new assessment.
  • CAA Guideline – View CAA Guidelines (Can only use while in Section V of the MDS) – See CAA Summary below for instructions.
  •   Add Diagnose – Add a diagnosis to the MDS as well as Resident Diagnose List (Can only use while in Section I of the MDS).
  • Print – Print the Assessment.
  • Section Notes – Add notes pertaining to a specific section of the MDS (i.e. resident started on a new anti-psychotic medication which could be reason for increase/decrease in behaviors) – See Section Notes below for instructions
  • Quick Save – Save while remaining in the assessment.
  • Auto Save – Set the autosave frequency.


Edit CAA Guidelines

Click  CAA Guideline.

 

You must be in Section V of the MDS. The CAAs will be listed in a column on the left side. The bolded CAAs are the ones that triggered based on the information given in the MDS assessment.

 

Select the triggered CAA.

 



Edit CAA

Select Edit icon in upper right corner. 


 

Review of Indicators

 

Applicable indicators will be checked in the left column. Review ALL checked indicators and enter supporting documentation in the right column.

 

Resident/Family/Representative Input 

 

Complete any recommendations from the Resident, family member or staff.


 

Analysis of Findings

 

Document the decision to care plan or not. In the left column, state the analysis of your findings, your conclusions, and any risk factors associated with your findings. In the right column, document the reasons why/why not you will care plan. If you do NOT care plan, leave the "Care Plan (Y/N)" box empty.

When finished, click Save

 

You can now lock the CAA to prevent other users from making changes.

Select the Signatures icon in the upper right corner

 

The Signatures box will display

 

Select Add Signature

 

The system will automatically assign your electronic signature and date to the CAA Guideline

 

When finished, select Close

 

NOTE: Additional signatures can be added by selecting Add Signature and completing the process again.

 

Care Plan

If you do NOT care plan, you will need to return to Section V and complete the documentation location for that CAA


 

If you do decide to care plan:

 

Select Care Plan Yes .

 

Click Care Plan .

 

You will be redirected to the Care Plan screen to complete. See the Care Plans section for instructions.

 

Repeat these steps until all CAA's are completed.

 

 

 

Click Save when finished.

 

 

 

Return to Section V of the MDS.

 

Question V0200 Column B will be filled in with a Checkmark. The Location and Date of the CAA Documentation field is populated with the CAA name and date it was completed. You can change the date in the location field by typing over it, if needed.


 

Section Notes

Click Section Notes

The MDS Section Notes will display


 

Select the Add icon in the upper right corner

 

Select MDS Section from the drop down list

 


T ype note in space provided

 

 

NOTE: Use word functionality to change font, insert tables or spell check.

 

When finished, select Save



 

Continue these steps to complete notes on multiple sections.

Once all Section Notes are completed, select Close



 



 

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