Roles and Responsibilities in Completing MDS 3.0 Sections: An Interdisciplinary Approach in Long-Term Care Facilities
The Minimum Data Set (MDS) 3.0 is a comprehensive tool used in the United States to assess residents' functional capabilities and healthcare needs in long-term care facilities. The MDS is used to inform care planning and determine reimbursement rates. It is divided into various sections, each designed to capture specific aspects of a resident's health, well-being, and care requirements. Here is an overview of the sections of the MDS 3.0 and the general responsibilities of different departments in completing them:
Section A: Identification Information
- Responsible: Administrative staff typically handle this section, which includes basic resident identification information and assessment reference dates.
Section B: Hearing, Speech, and Vision
- Responsible: Nursing staff, often with input from specialists as needed, assess hearing, speech, and vision capabilities.
Section C: Cognitive Patterns
- Responsible: Nursing staff, sometimes in collaboration with a psychologist or a trained mental health professional, assess cognitive patterns, including memory and decision-making abilities.
Section D: Mood
- Responsible: Nursing staff or social services, utilizing standardized assessment tools like the PHQ-9 for depression screening.
Section E: Behavior
- Responsible: Nursing staff, in collaboration with social services and possibly psychiatric professionals, document behaviors such as aggression, rejection of care, and other significant actions impacting care or the environment.
Section F: Preferences for Customary Routine and Activities
- Responsible: Activities Director or nursing staff interviews residents to understand their preferences, interests, and routine activities to inform individualized care planning.
Section G: Functional Status
- Responsible: Nursing staff, often with input from physical and occupational therapists, assess the resident's functional abilities and limitations in activities of daily living (ADLs).
Section H: Bladder and Bowel
- Responsible: Nursing staff assess the resident's continence status, including any appliance use, patterns of incontinence, and bowel management.
Section I: Active Diagnoses
- Responsible: Nursing staff, in conjunction with the resident's physician, document active medical diagnoses that impact care planning and interventions.
Section J: Health Conditions
- Responsible: Nursing staff, with possible consultation from specialized healthcare providers, document health conditions affecting the resident, such as pain management, falls, and surgical history.
Section K: Swallowing/Nutritional Status
- Responsible: Dietitians and nursing staff assess nutritional status, swallowing disorders, and the need for specialized diets or feeding programs.
Section L: Oral/Dental Status
- Responsible: Nursing staff, sometimes with assessments from dental professionals, document the resident's oral and dental health.
Section M: Skin Conditions
- Responsible: Nursing staff, particularly wound care nurses, if available, assess and document skin conditions, including pressure ulcers/injuries.
Section N: Medications
- Responsible: Nursing staff, in collaboration with the facility's pharmacist, document medications the resident is receiving and monitor for potential side effects or interactions.
Section O: Special Treatments and Procedures
- Responsible: Nursing staff, along with physical, occupational, and speech therapists, document special treatments, therapies, and procedures the resident is receiving.
Section P: Restraints
- Responsible: Nursing staff document the use of any physical restraints or safety devices employed to prevent falls or self-harm.
Section Q: Participation in Assessment and Goal Setting
- Responsible: Social services and nursing staff engage the resident and, if applicable, their family or representative in the assessment process and goal setting for care planning.
Section S: State-Specific Items
- Responsible: Depending on the state-specific requirements and the data needed, various staff members may be involved.
Section V: Care Area Assessment (CAA) Summary
- Responsible: In coordination with the interdisciplinary team, nursing staff summarize the CAAs' results to identify care priorities and plan interventions.
Section Z: Assessment Administration
- Responsible: The MDS Coordinator (often a role within the nursing department) oversees the completion of the MDS, ensuring all sections are accurately filled out and submitted in compliance with regulatory deadlines.
Each section of the MDS 3.0 requires careful attention and collaboration among various interdisciplinary team members to ensure a comprehensive assessment of the resident's needs and the development of an effective, individualized care plan.
Feedback Form
