Sherry et al:
Below is a section of Illinois Amdinistrative Code 300.1810, Resident
Record Requirements (italics mine). Note the reference is to physician use
of a rubber stamp. This may be what the surveyor was referring
to. I could find no reference in the Illinois Adm. Code that
addressed staff use of a rubber stamp, but if the physician is
not allowed, I can see the surveyors following the logic that staff couldn't
either. This section if the IAC also addresses the issue of an
electronic medical record. It can be accessed at http://www.legis.state.il.us/commission/jcar/admincode/077/07700300sections.html
Please respond to me privately - I'd be interested in knowing who
was doing the presenting!
Nancy
[EMAIL PROTECTED]
d)
All physician's orders, plans of treatment, Medicare or Medicaid certification,
recertification statements, and similar documents shall have the authentication
of the physician. The use of a physician's rubber stamp signature,
with or without initials, is not acceptable.
(Source:
Amended at 23 Ill. Reg. 8106, effective July 15, 1999)
----- Original Message -----
Sent: Saturday, February 21, 2004 12:12
PM
Subject: Re: Second try - Surveyors here!
Who needs to sign the MDS?
Have been participating in a Life Services Network audioconference series
on the RAI process over the last few weeks. The presenter is a former
Public Health Surveyor, just stopped doing it in the last few
months. She specifically said that when she was covering the signature
requirements. Of course, we know surveyors are sometimes not quite clear
on things, but she seemed very sure. Should I take it with a grain of
salt, do you think?
Sherry
Nathan <[EMAIL PROTECTED]>
wrote:
Where did you learn this and in what context? Rubber
stamping has a number of uses. In some situations the States may have regs
governing their use, but they don't write the CMS/MDS policies.
Nathan
----- Original Message -----
Sent: Friday, February 20, 2004 1:53
PM
Subject: Re: Second try - Surveyors
here! Who needs to sign the MDS?
I learned 2 wks ago that rubber signature stamps are NOT allowed in
IL.
In
my opinion you may have a problem. While rubber stamps are allowed,
the
intent was that everyone completing part of the MDS would apply
their rubber
stamp to the paper form. CMS still has no official
policy regarding the type
of electroinic signing of the MDS that you
are talking about. In talking to
various people at CMS they verbally
state that a secure system, such as you
apparently have, should be
ok, but there is nothing in writing to that
effect. The MDS is still
a paper system and relies on putting ink to the
paper for a
signature. If there is an appeal process, you may be able to
argue
the case. All the software vendors will be very interested in
the
outcome as we have been rying to decide where to go with this
issue..
Good luck.
Nathan
-----
Original Message -----
From: "Doyle, Renee"
<[EMAIL PROTECTED]>
To: <[EMAIL PROTECTED]>
Sent: Friday,
February 20, 2004 11:18 AM
Subject: Second try - Surveyors here! Who
needs to sign the MDS?
> Sent this yesterday and got only
one response. Surveyors are here -
please
> respond if
possible. Thanks!
>
> Currently in the middle of a Public
Health survey (Illinois), and they
> aren't happy that I (RNAC) am
the only one signing the MDS. We have an
> electronic audit trail
that shows each entry made to the
> MDS/Date/Time/Name/Credentials
and have a policy in place to support the
> electronic signature.
I told them that although other people enter
> information in the
computerized form, I am the one to
review/edit/complete
> the
form. They were not happy with this explanation. Page 3-212 of
the
MDS
> manual says under Clarifications: The use of
signature stamps is allowed
> (with policies in place). This was
brought up on a past inspection, at
> which time no one was
physically signing (before my time), and they said
> that an RN
must sign in all places. Since I have been here (3 yrs) I have
>
been signing in every place needing a signature. They had been fine
with
> that until today. Now, they want everybody to sign. I think
I have read
in
> the past on this listserve that other SNF's
also have only the RNAC sign
> without a problem. Do I have a case
or am I out of compliance with the
> policy? Please respond ASAP
as they are due back in the a.m. with the
exit
> interview at 2
pm. By the way, they also thought the 5 day MDS had to be
> done
by day 5! They also couldn't understand why I wasn't doing a
5-day
> Medicare on my Insurance patients. They told me you can't
just pick any
day
> you want for the reference day. I had to
copy several pages of the manual
> to show them because they
didn't believe me! Then I made the mistake of
> giving them the
manual to look at when they asked me for a copy. I think
> they
were embarrassed to be so uninformed. So, they are probably
looking
> for anything they can think of...
>
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