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Q:
Must Z0400 be signed if there is supporting documentation in the record with the name and date completed by the correct staff member?
A:
All staff who completed any part of the MDS must enter their signatures, titles, sections or portion(s) of the section(s) they completed, and the date completed at Z0400. If there is supporting documentation (as for the BIMS, for example) ZO400 should reflect the date that the BIMS was conducted and by whom. Per the RAI: If a staff member cannot sign Z0400 on the same day that he or she completed a section or portion of a section, when the staff member signs, use the date the item originally was completed.
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Blog by Eleisha Wilkes, RN, RAC-CTA, Clinical Consultant, Proactive Medical Review
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