MDS Alert

Reader Questions:

Use Medical Record in This No Signature Situation

Question: The colleague who was responsible for filling out much of a resident’s MDS no longer works here and therefore cannot make the attestation statement. What do I do?

Alabama Subscriber

Answer: You can have options for attesting the accuracy of the MDS even if you can’t get the signature from the person who completed it, according to the RAI Manual.

“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,” the RAI Manual says, page Z-6.