Step-by-Step Coding Guide for Item Set Z0400C: Attestation Signature, Title, Sections, Date

1. Review of Medical Records

• Begin by reviewing the sections of the MDS that have been completed and require attestation. Verify that all data are accurately captured and reflect the current status and care needs of the resident.
• Confirm the qualifications and authority of the individual who will sign the attestation, ensuring they are authorized to complete this part of the MDS.

2. Understanding Definitions

• Attestation: A formal declaration by the signer that the information within the MDS is accurate to the best of their knowledge, and it adheres to applicable regulations and guidelines.
• Title: The official or professional title of the individual attesting to the MDS.
• Sections: The specific parts of the MDS that the attestation covers.
• Date: The date on which the attestation is signed, indicating when the review was completed and verified.

3. Coding Instructions

• Input the full legal name of the individual responsible for the MDS attestation.
• Specify the professional title (e.g., RN, Director of Nursing, MDS Coordinator) of the attesting individual.
• 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 is the actual date the MDS review was completed.

4. Coding Tips

• Ensure the name and title are accurately spelled and reflect the current status of the individual signing the MDS.
• Make sure the attestation covers all relevant sections of the MDS that were reviewed by the attesting individual.
• Confirm that the date of attestation corresponds with the date the MDS was reviewed and finalized.

5. Documentation

• Maintain a record of the attestation within the resident's healthcare file, including the name, title, sections reviewed, and date of attestation.
• Implement a protocol for attestation in your facility’s MDS completion procedures to maintain consistency and ensure compliance.

6. Common Errors to Avoid

• Having someone without the proper authority or credentials sign the attestation.
• Incorrectly dating the attestation or failing to include all reviewed sections of the MDS.
• Neglecting to verify the accuracy of the information in the MDS before attestation, leading to potential inaccuracies.

7. Practical Application

• Example: Mary Johnson, RN, the facility’s MDS Coordinator, completes the MDS for a resident on September 15, 2024. She reviews and verifies the accuracy of sections F through J, ensuring all data align with the resident’s current health status and care plans. After her review, she signs the attestation on Z0400C, entering her name, title, the sections covered, and the date of September 15, 2024. This attestation confirms that the documented information meets all regulatory requirements and is ready for submission.

Please note that the information provided in this guide for MDS 3.0 Item set Z0400C 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.