Step-by-Step Coding Guide for Item Set Z0400A: Attestation Signature, Title, Sections, Date

1. Review of Medical Records

• Begin by reviewing the completed sections of the MDS that require attestation. Ensure that all information has been reviewed and is accurate before the attestation process.
• Confirm the identity and qualifications of the individual who will sign the attestation, verifying their role and authority to complete this section.

2. Understanding Definitions

• Attestation: The act of signing off on the MDS, certifying that the data entered is accurate to the best of the signer's knowledge and that it complies with all applicable regulations.
• Title: The professional title of the individual attesting to the MDS.
• Sections: The specific sections of the MDS that the attestation covers.
• Date: The date on which the attestation is signed, indicating when the review was completed.

3. Coding Instructions

• Enter the full legal name of the individual responsible for the MDS.
• Specify the professional title (e.g., RN, BSN, MDS Coordinator) of the individual attesting to the accuracy of the MDS.
• List the sections of the MDS that have been reviewed and are being attested to.
• Record the date on which the attestation is made, ensuring it matches the completion date of the MDS sections being attested.

4. Coding Tips

• Double-check that the name and title entered are spelled correctly and reflect the current status of the individual signing the MDS.
• Ensure that the date of attestation is the actual date the individual reviewed and signed off on the MDS.

5. Documentation

• Maintain a record of all personnel authorized to attest to the MDS, including copies of licenses or certifications as applicable.
• Keep a log or electronic record of all attestation dates and the corresponding sections of the MDS that were reviewed, to support audits or inspections.

6. Common Errors to Avoid

• Having an unauthorized or unqualified individual sign the attestation.
• Failing to include the correct date or misstating the sections of the MDS that were reviewed.
• Neglecting to verify that all information in the MDS is accurate and complete prior to attestation.

7. Practical Application

• Example: An MDS Coordinator, Jane Doe, RN, completes the MDS for a resident on March 15, 2024. After reviewing sections A, B, C, and D for accuracy and completeness, she signs the attestation on the same day, March 15, 2024, confirming that the information is correct to the best of her knowledge. Jane enters her name, title, the sections attested to, and the date in Z0400A accordingly.

Please note that the information provided in this guide for MDS 3.0 Item set Z0400A 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.