Who must complete the Minimum Data Set (MDS) in a nursing home?

The Minimum Data Set (MDS) is a comprehensive assessment tool used in nursing homes to evaluate the functional capabilities and needs of residents. The primary responsibility for completing the MDS falls on the nursing staff, specifically registered nurses (RNs) or licensed practical nurses (LPNs) trained in the MDS process. They have the expertise required to gather and assess clinical data about the resident's health status, preferences, and care needs.

Nursing staff play a crucial role in the MDS process, as they are closely involved in the daily care of residents and have direct access to their clinical information. This ensures that the assessment is accurate and reflects the current condition of the resident, which is essential for proper care planning and reimbursement processes.

While other professionals, such as the facility administrator, the physician treating the patient, and the social worker, contribute to the overall care of residents, their roles typically do not include the direct completion of the MDS. Instead, they may provide relevant information or support to the nursing staff during the assessment process and care planning.