1. A home health nurse is preparing for an initial home visit. Which
information should be included in the patient’s home care medical record?
a. Nursing process form
b. Step-by-step skills manual
c. A list of po
...
1. A home health nurse is preparing for an initial home visit. Which
information should be included in the patient’s home care medical record?
a. Nursing process form
b. Step-by-step skills manual
c. A list of possible procedures
d. Reports to third-party payers
ANS: D
Information in the home care medical record includes patient assessment, referral and intake forms, interprofessional plan of care, a list of medications, and reports to third-party payers. An interprofessional plan of care is used rather than a nursing process form. A step-by-step skills manual and a list of possible procedures are not included in the record.
2. A nurse in a long-term care setting that is funded by Medicare and
Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which task is the nurse completing?
a. A minimum data set
b. An admission assessment and acuity level
c. A focused assessment/specific body system
d. An intake assessment form and auditing phase ANS: A
The Resident Assessment Instrument (RAI), which includes the Minimum Data Set (MDS) and the Care Area Assessment (CAA), is the data set that is federally mandated for use in long-term care facilities by CMS. MDS assessment forms are completed upon admission, and then periodically, within specific guidelines and time frames for all residents in certified nursing homes. The MDS also determines the reimbursement level under the prospective payment system. A focused assessment is limited to a specific body system. An admission assessment and acuity level is performed in the hospital. An intake form is for home health. There is no such thing as an auditing phase in an assessment intake.
3. A nurse is charting. Which information is critical for the nurse to document? 1
a. The patient had a good day with no complaints
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