The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing facilities. The entire process, called the Resident Assessment Instrument (RAI), provides a comprehensive assessment of each resident's functional capabilities and helps nursing facility staff identify health problems. Resident Assessment Protocols (RAPs) are part of this process and provide the foundation upon which a resident's individual care plan is formulated. MDS assessment forms are completed for all residents in certified nursing facilities, regardless of source of payment for the individual resident. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. In most cases, participants in the assessment process are licensed health care professionals employed by the nursing facility, sometimes referred to as the MDS or RAI Coordinator. MDS information is transmitted electronically by nursing facilities to the MDS database in their respective states. MDS information from the state databases is captured into the national MDS database at the Centers for Medicare and Medicaid (CMS). The information filled out on the MDS determines the Resource Utilization Group (RUG) category, which ultimately determines the per diem rate paid to the facility for a resident whose stay is covered under Medicare Part A. The MDS data also feeds into the facility’s quality indicator and quality measure reports, some of which are publicly reported and some of which are used by surveyors during the survey process.
MDS 3.0 has been designed to improve the reliability, accuracy, and usefulness of the MDS, to include the resident in the assessment process, and to use standard protocols used in other settings.
Consultant pharmacists should utilize MDS data when conducting medication regimen reviews for nursing facility residents, as it contains valuable insight and information into medication-related problems and effectiveness of medications. A hard-copy version of the MDS may be found on the resident’s chart, but facilities are no longer required to maintain a hard-copy on the chart. If they maintain copies of their MDS electronically only, ask the MDS/RAI coordinator or Director of Nursing for a copy.
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