Step-by-Step Coding Guide for Item Set X1100D: Correction: Attestor Signature

1. Review of Medical Records

• Objective: Ensure that the attestor’s signature on the MDS is correctly captured and corresponds to the individual who verified and approved the MDS.
• Action: Review the MDS documentation to verify that the signature matches the attestor’s name and title as recorded and is consistent with signatures on other official documents.

2. Understanding Definitions

• Attestor Signature: The physical or electronic signature of the healthcare professional responsible for attesting to the accuracy and completion of the MDS. This signature validates the document’s contents and compliance with regulatory requirements.

3. Coding Instructions

• Verify the Signature: Confirm that the signature on the MDS belongs to the attestor listed and matches the signature style typically used by them, as found on other legal documents.
• Correct the Signature in MDS: If the signature is missing, incorrect, or does not match, update the MDS with the correct signature. Ensure that the attestor re-signs the document if necessary.

4. Coding Tips

• Signature Consistency: Check for consistency in the signature across various documents. Discrepancies might indicate a clerical error or misuse.
• Electronic Signatures: If using electronic signatures, ensure they are secured and comply with healthcare regulations.

5. Documentation

• Record of Corrections: Keep detailed records of the original and corrected signatures, why the correction was needed, and the evidence supporting the change.
• Audit Trail: Document who identified the discrepancy, who authorized the correction, and when it was corrected.

6. Common Errors to Avoid

• Signature Omission: Ensure that no attestor’s signature is accidentally omitted from the MDS.
• Unauthorized Signatures: Verify that only authorized individuals sign the MDS, avoiding the use of proxy or unauthorized signatures.
• Incorrect Signature Updates: When updating signatures, ensure the correct procedure is followed to maintain document integrity and compliance.

7. Practical Application

• Example: During a routine audit, it was noticed that the attestor’s signature on the MDS appeared different from the signature on file. Upon investigation, it was determined that an administrative assistant had mistakenly placed a scanned signature of a different staff member. The correct attestor, an MDS Coordinator, was then asked to re-sign the MDS document. The correction was documented on July 10, 2024, and included in the facility’s compliance log with a note explaining the mistake and the steps taken to rectify it.

Please note that the information provided in this guide for MDS 3.0 Item setX1100D 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.