MDS Data Entry

Be aware that, although you can sometimes copy and paste information in PointClickCare, you must ensure that documentation is complete and accurate.

Risks associated with copying and pasting information into a resident record:

Resident safety and quality of care: identical wording could indicate failure to reassess.
Breach of resident’s privacy: if copying from another resident’s chart, omit any identification and verify accuracy.
Insurance fraud: identical language day after day or between residents is an indicator of fraud to Medicare and other insurers.
Denial of payment: identical language may lead to a refusal of payment upon chart review.

When copying and pasting, be sure to reassess and reword accordingly. If the resident’s condition is identical, it is still recommended to change some of the wording to avoid the above issues.

Skilled Nursing Facilities

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MDS Data Entry