DiraChart MDS item reference
Z0400Section Zv1.20.1Manual page Z-5
Signatures of Persons Completing the Assessment or Entry/Death Reporting
Entry/Death Reporting (cont.)
Quick codingAnswer Codes
Use the item-specific response choices below when structured codes apply.
Response format: Instruction / group heading
This row introduces a grouped MDS item. Complete the applicable child items shown in the current item set.
Item-specific instructionsCoding Guidance
Review what the item asks, how to choose the response, and what should be verified before submission.
RAI Manual v1.20.1Coding Instructions
•
All staff who completed any part of the MDS must enter their signatures, titles, sections
or portion(s) of section(s) they completed, and the date completed.
•
If a staff member cannot sign Z0400 on the same day that they completed a section or
portion of a section, when the staff member signs, use the date the item originally was
completed.
•
Read the Attestation Statement carefully. You are certifying that the information you
entered on the MDS, to the best of your knowledge, most accurately reflects the
resident’s status. Penalties may be applied for submitting false information.
Manual page Z-5RAI Manual v1.20.1Coding Tips
and Special Populations
•
Two or more staff members can complete items within the same section of the MDS.
When filling in the information for Z0400, any staff member who has completed a sub-
set of items within a section should identify which item(s) they completed within that
section.
•
Nursing homes may use electronic signatures for medical record documentation,
including the MDS, when permitted to do so by state and local law and when authorized
by the nursing home’s policy. Nursing homes must have written policies in place that
meet any and all state and federal privacy and security requirements to ensure proper
security measures to protect the use of an electronic signature by anyone other than the
person to whom the electronic signature belongs.
•
Although the use of electronic signatures for the MDS does not require that the entire
record be maintained electronically, most facilities have the option to maintain a
resident’s record by computer rather than hard copy.
•
Whenever copies of the MDS are printed and dates are automatically encoded, be sure to
note that it is a “copy” document and not the original.
Z0400: Signatures of Persons Completing the Assessment or
Entry/Death Reporting (cont.)
•
If an individual who completed a portion of the MDS is not available to sign it (e.g., in
situations in which a staff member is no longer employed by the facility and left MDS
sections completed but not signed for), there are portions of the MDS that may be
verified with the medical record and/or resident/staff/family interview as appropriate. For
these sections, the person signing the attestation must review the information to assure
accuracy and sign for those portions on the date the review was conducted. For sections
requiring resident interviews, the person signing the attestation for completion of that
section should interview the resident to ensure the accuracy of information and sign on
the date this verification occurred.
Manual page Z-5 MDS item matrixAssessment Applicability
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11 relationships4 groups+
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