Step-by-Step Coding Guide for Item Set X1100E: Correction: Attestation Date

1. Review of Medical Records

• Objective: Confirm that the attestation date recorded in the MDS accurately reflects the actual date on which the attestor signed and verified the MDS document.
• Action: Review the attestor’s records, MDS submission logs, and communication records to verify the correct date of attestation.

2. Understanding Definitions

• Attestation Date: The date when the MDS was officially signed off by the attestor, affirming that the information within the document is accurate and complete.

3. Coding Instructions

• Verify the Attestation Date: Ensure that the attestation date listed in the MDS matches the date the attestor actually signed the document, as verified by internal records or digital signature logs.
• Correct the Date in MDS: If discrepancies are found, update the MDS to reflect the accurate attestation date.

4. Coding Tips

• Documentation Alignment: Cross-reference the attestation date with emails, electronic logs, and other communication to ensure accuracy.
• Accuracy in Record-Keeping: Be meticulous when entering or correcting dates to prevent future discrepancies.

5. Documentation

• Detailed Record-Keeping: Keep a record of the original incorrect date, the verified correct date, and the reason for the discrepancy.
• Audit Trail: Document who identified the error, who authorized the correction, when the correction was made, and the evidence used to justify the correction.

6. Common Errors to Avoid

• Inaccurate Date Entry: Ensure the date is not incorrectly recorded due to clerical errors or misunderstandings.
• Delay in Correction: Address any discrepancies in the attestation date as soon as they are identified to maintain the integrity of the document.
• Inadequate Verification: Avoid making corrections without sufficient documentary evidence to support the change.

7. Practical Application

• Example: During an internal audit, it was discovered that the attestation date on the MDS for resident Jane Doe was recorded as May 25, 2024. However, upon reviewing the digital signature log, it was clear that the attestor had signed the document on May 24, 2024. The MDS Coordinator reviewed the electronic signature details, confirmed the discrepancy, and corrected the attestation date in the MDS. This correction was documented on June 1, 2024, along with references to the digital signature log as evidence.

Please note that the information provided in this guide for MDS 3.0 Item set X1100E 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.