MDS Alert
An EMR System Can Boost Documentation Prowess
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Follow this facility's lead. Good Shepherd Nursing Home has found a secret weapon to help the facility find the right medical record documentation to supports its MDS - one that also allows it to make the most of nurses' skilled observations.
The facility's electronic medical record (EMR) system links the supporting documentation to each answer of the MDS. "The system knows where to look for it - even across multiple disciplines," reports John Ederer, a licensed nursing home administrator and president of American Data in Sauk City, WI, which provides the facility's software. The EMR system also helps nurses capture their skilled assessments by taking documentation to the bedside, which improves MDS accuracy and care planning.
"When nurses do the medication or treatment pass, they enter their assessments into the EMR using a small laptop on top of the medication and treatment cart," Ederer explains. "Without that capability, the nurse can lose or not record a lot of good assessment information," Ederer says. "The laptop computer on the med and treatment cart also allows the nurse to review the resident's physician orders, the most recent documentation and the pharmacy consultant's report, etc., without having to spend time at the nurses' station."
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