Z0400: Signatures of Persons Completing the Assessment or Entry/Death Reporting

Z0400: Signatures of Persons Completing the Assessment or Entry/Death Reporting

Item Rationale

To obtain the signature of all persons who completed any part of the MDS. Legally, it is an attestation of accuracy with the primary responsibility for its accuracy with the person selecting the MDS item response. Each person completing a section or portion of a section of the MDS is required to sign the Attestation Statement.

The importance of accurately completing and submitting the MDS cannot be over- emphasized. The MDS is the basis for:

the development of an individualized care plan

the Medicare Prospective Payment System

Medicaid reimbursement programs

quality monitoring activities, such as the quality measure reports

the data-driven survey and certification process

the quality measures used for public reporting

research and policy development.

Coding Instructions

All staff who completed any part of the MDS must enter their signatures, titles, sections or portion(s) of section(s) they completed, and the date completed.

If a staff member cannot sign Z0400 on the same day that they completed a section or portion of a section, when the staff member signs, use the date the item originally was completed.

Read the Attestation Statement carefully. You are certifying that the information you entered on the MDS, to the best of your knowledge, most accurately reflects the resident’s status. Penalties may be applied for submitting false information.

Coding Tips and Special Populations

Two or more staff members can complete items within the same section of the MDS. When filling in the information for Z0400, any staff member who has completed a sub- set of items within a section should identify which item(s) they completed within that section.

Nursing homes may use electronic signatures for medical record documentation, including the MDS, when permitted to do so by state and local law and when authorized by the nursing home’s policy. Nursing homes must have written policies in place that meet any and all state and federal privacy and security requirements to ensure proper security measures to protect the use of an electronic signature by anyone other than the person to whom the electronic signature belongs.

Although the use of electronic signatures for the MDS does not require that the entire record be maintained electronically, most facilities have the option to maintain a resident’s record by computer rather than hard copy.

Whenever copies of the MDS are printed and dates are automatically encoded, be sure to note that it is a “copy” document and not the original.

If an individual who completed a portion of the MDS is not available to sign it (e.g., in situations in which a staff member is no longer employed by the facility and left MDS sections completed but not signed for), there are portions of the MDS that may be verified with the medical record and/or resident/staff/family interview as appropriate. For these sections, the person signing the attestation must review the information to assure accuracy and sign for those portions on the date the review was conducted. For sections requiring resident interviews, the person signing the attestation for completion of that section should interview the resident to ensure the accuracy of information and sign on the date this verification occurred.