Hi-Tech will not be responsible if your hardware fails and you lose your residents medical record documentation and/or MDS records.

Transcription

1 Overview... 1 Prepare fr E-Signatures... 1 Set Up Electrnic Signatures fr Clinical Assessments, Ntes and the MDS Put Users Electrnic Signatures n File... 2 Select Recrds t be Signed Electrnically... 2 E-Sign MDS Recrds fr Facility r by Unit?... 2 Electrnically Sign the MDS Re-pening an E-Signed MDS... 4 Print Signature Pages Only... 4 E-Sign Cmpleted Ntes r Clinical Assessment Recrds... 5 Overview Befre yu begin using the Hi-Tech electrnic signatures (e-signatures) features, yur facility must have an e- signature plicy. The CMS RAI Versin 3.0 Manual, Sectin Z, Page 7 states: Nursing hmes may use electrnic signatures fr medical recrd dcumentatin, including the MDS, when permitted t d s by state and lcal law and when authrized by the nursing hme s plicy. Nursing hmes must have written plicies in place that meet any and all state and federal privacy and security requirements t ensure prper security measures t prtect the use f an electrnic signature by anyne ther than the persn t whm the electrnic signature belngs. Prepare fr E-Signatures Verify with yur State MDS Help desk that yur state allws fr electrnically signed medical recrd dcumentatin and MDS recrds. Create a facility Electrnic Plicy: Anyne wh will electrnically sign recrds shuld sign an agreement that they will be electrnically signing residents medical recrd dcumentatin and MDS recrds. Stre these agreements in a secure lcatin. Ensure that smene is available 24/7 t prduce printed cpies f these recrds. Surveyrs will want t see printed cpies. Wrk with yur IT staff r hardware vendr t establish a fl-prf back-up prcess that verifies yur daily backup is cmplete and useable. Back up yur system at least nce a day t guard against lss f these essential recrds. Hi-Tech will nt be respnsible if yur hardware fails and yu lse yur residents medical recrd dcumentatin and/r MDS recrds. (207) Page 1

2 Set Up Electrnic Signatures fr Clinical Assessments, Ntes and the MDS 3.0 Put Users Electrnic Signatures n File 1. Decide which Users will electrnically sign recrds. 2. Select Utilities > System Structure > Maintenance > Users/Security > Edit User Infrmatin 3. Enter the User ID and checkmark Signature n File. Select Recrds t be Signed Electrnically 1. Select Libraries > Facility > Clinical Prfile. Click OK twice t display Screen 3 (n right). 2. Under Electrnic Medical Recrd Optins select recrds t be signed electrnically: MDS 3.0 Signature plicy in place (by Facility) MDS 3.0 Signature plicy in place (by Unit) Ntes Print Signature (see page 5) Assessments Print Signatures (see page 5) E-Sign MDS Recrds fr Facility r by Unit? When yu e-sign an MDS yu maintain the entire recrd electrnically and print n pages fr the chart. There are tw ptins fr: MDS 3.0 Signature plicy in place. By Facility: require electrnic signatures n all residents MDS recrds. By Unit: require electrnic signatures n MDS recrds fr residents n specific units. This allws yu t phase in the plicy unit-by-unit. Specify the Units thrugh Libraries > Facility > Units (belw): Select the Cst Center. Type = Rm. Checkmark MDS 3.0 Signature plicy in place OPTION: If yu select By Unit, yu might want t select the ptin, Print Signature Page X, V & Z Only, t print and sign the Signature Page n the units that d nt e-sign the MDS. See Page 4 fr detail. IMPORTANT: Once yu implement the e-signature prcess, yu must e-sign all MDS recrds (n selected units r facility-wide) t Cmplete them fr submissin. (207) Page 2

3 Electrnically Sign the MDS 3.0 T e-sign the recrd, the user wh lgs int the System must have a Signature n file in his/her User ID recrd. See previus page under Put Users Electrnic Signatures n File. At Sectins V, X and Z, select Electrnic Signature r Elec. t display the signer s name. Enter the Date. Nte: Yu can uncheck yur wn Electrnic Signature, but nt anther User s signature. Final Signature at Z500A: When yu select Electrnic Signature, the recrd will be checked fr errrs. If there are n errrs in the recrd, yur name will be displayed, and yu can enter the date. If there are errrs, the screen will display: WARNING: MDS has Errrs Signature nt allwed. Yu can view the errrs and return t thse sectins t crrect them. (207) Page 3

4 When yu end ut f an errr-free, e-signed recrd, the final screen defaults t a checkmark at: Cmplete Frm (if Errr Free) by e-signature. With this item checked, click Cntinue. NOTE: Select Print the Frm (if Errr Free) if yu als want t print the recrd. This will launch the Print MDS prgram. An errr-free MDS will be given a Status f Cmplete s that it can be submitted. See belw. Re-pening an E-Signed MDS If yu attempt t pen a Cmpleted MDS recrd that was e- signed by anther user, the screen will display the Warning: e-signed by USER NAME Clear signature? e-signed by e-signed by Clear signature? Click Yes. This will clear the electrnic signature and re-pen the recrd. An authrized user must again electrnically sign the recrd t Cmplete it fr submissin. Print Signature Pages Only MDS 3.0 Print Signature Page X, V & Z Only: Select this ptin if yu want t print just the Signature Pages fr manually signing and placing in the chart. Select Include Page 1 f Sectin A if yu want t print a cver page that identifies the assessment. This will cause the Print MDS prgram t select t Print Signature Page(s) Only. See belw. The entire MDS will be stred electrnically. OPTION: Yu can select the Print Signature pages ptin if yu have selected MDS 3.0 Signature plicy in place (by Unit) and yu want t print MDS Signature pages fr the units that d nt e-sign MDS recrd. See Page 2. When yu end ut f the recrd, Print the Frm (If Errr Free) will be selected. Click Cntinue t launch Print MDS, which will display a screen similar t the ne belw with Signature Page(s) Only selected. Printing with this item checked will Cmplete the recrd fr submissin. (207) Page 4

5 E-Sign Cmpleted Ntes r Clinical Assessment Recrds Dcumentatin > Clinical Assessments > Edit Assessment: When yu cnsider a recrd t be cmplete, select Assessment Cmplete (Lcked & Signed). Dcumentatin > Ntes > Edit Ntes: When yu cnsider a recrd t be cmplete, select Nte Cmplete (Lcked & Signed). After a recrd is signed, yu cannt change it; hwever, yu can inactivate a recrd that has errrs. (207) Page 5