Definitions
A type of living arrangement where some personal care services are available but residents still live on their own.
What is assisted living?
Instrument used to collect information about a resident in a SNF or NF.
What is Resident Assessment Instrument (RAI)?
Physician's approval in writing that an individual be admitted to a facility.
What is admission order?
Documents an interdisciplinary team effort to assess a resident's needs, abilities, preferences, and readiness to learn.
What is Education Records?
Documentation required by the federal government for all Medicare beneficiaries that supports the need for skilled services.
What is Medical Necessity?
Term used to define the care provided by a long-term care facility for MEDICAID regulation and reimbursement purposes.
What is a nursing facility (NF)?
The component of the RAI that provides standardized data points to assist in communication about resident problems, illnesses, and other conditions within nursing facilities.
Short documentation that is required upon admission as well as each time a resident is seen by a physician during their stay.
What is progress notes?
Documentation of routine actions such as eating, bathing, dressing, and toileting.
What is Activities of Daily Living?
What is Physician Certification?
Term used to define the care provided by a long-term care facility for MEDICARE regulation and reimbursement purposes.
What is skilled nursing facility (SNF)?
Process that helps staff systematically interpret care areas that have been identified as potential problems on the MDS.
What is the Care Area Assessment (CAA) process?
The Joint Commission requires that this important documentation be completed within 24 hours before admission or within 72 hours after.
What is History and Physical?
Evaluation, education, management, and treatment notes from physical, occupational, speech-language, and respiratory therapists.
What is Rehabilitative Therapy documentation?
Document that outlines Medicare requirements for nursing facilities.
What is Medicare Conditions of Participation?
Original legislation that addressed skilled nursing care.
What is the Social Security Act (SSA)?
Instructions for when and how to complete the RAI as well as how to appropriately utilize MDS information.
What is Utilization Guidelines?
This documentation provides details of a resident's stay and assures continuity of care upon their departure.
What is Discharge Summary?
Documentation used to capture the delivery of each drug given to a resident.
What is Medication Administration Records?
Accrediting body that helps ensure that consumers and their families have access to the best rehabilitative services available.
What is the Commission on Accreditation of Rehabilitation Facilities (CARF)?
Resource that provides guidelines for regulators of long-term care facilities.
What is State Operations Manual?
Used in conjunction with the MDS to ensure that a resident has a comprehensive assessment; "triggers" conditions that need additional assessment or review.
What is Resident Assessment Protocols (RAPs)?
This documentation is required whenever a resident is seen by a specialist regarding problems identified during his/her care and treatment at the nursing facility.
What is Physician Consultation?
Laboratory and diagnostic test results as well as imaging, pathology, EKG, pulmonary function reports.
What is Laboratory and Special Reports?
Piece of legislation that requires assessments used by a SNF to contain standardized uniform data that strengthens communication between providers.
What is the IMPACT Act of 2014?