Step-by-Step Coding Guide for Item Set X1100B: Correction: Attestor Last Name

1. Review of Medical Records

• Objective: Verify that the last name of the attestor (the individual who signs the MDS, verifying its accuracy and completion) is correctly recorded in the MDS.
• Action: Confirm the attestor's last name by checking it against official documentation such as employment records, professional licenses, or HR files.

2. Understanding Definitions

• Attestor: A healthcare professional, typically a nurse or MDS Coordinator, responsible for attesting to the accuracy and completion of the MDS.

3. Coding Instructions

• Verify the Last Name: Ensure the attestor’s last name listed in the MDS is consistent with that on their official identification or employment documentation.
• Correct the Name in MDS: If discrepancies are found, accurately update the MDS to reflect the correct last name.

4. Coding Tips

• Attention to Detail: Be meticulous in verifying the spelling of the last name to prevent common typographical errors.
• Maintain Confidentiality: Handle all personal information sensitively and confidentially during the verification process.

5. Documentation

• Detailed Record-Keeping: Keep records of the original entry, the evidence used for correction, and the corrected entry.
• Audit Trail: Document the correction process including who made the correction, when it was made, and the source of the correct information.

6. Common Errors to Avoid

• Inaccurate Verification Sources: Verify the last name using official and reliable sources only, to avoid incorrect corrections.
• Failing to Update Related Documents: Ensure that any change in the attestor’s name is consistently updated across all related MDS documents.

7. Practical Application

• Example: During a compliance review, it was noticed that the attestor's last name was misspelled in the MDS as "Smyth" instead of "Smith." The MDS Coordinator confirmed the correct spelling with the attestor’s employee ID and professional license, then updated the MDS accordingly. This correction was documented on May 15, 2024, with references to the license and employee record for verification and logged in the facility’s compliance records to maintain accuracy and transparency.

Please note that the information provided in this guide for MDS 3.0 Item set X1100B was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.