Resident Assessments
What key information must be documented during a resident's admission assessment?
Baseline physical condition, medical history, allergies, and psychosocial information.
What is the primary purpose of progress notes?
To document the care provided and the resident's response to care.
What must a care plan include to meet regulatory requirements?
Measurable goals, individualized interventions, and timelines for evaluation.
What is the most important legal rule for nursing documentation?
If it wasn’t documented, it wasn’t done.
What happens if a nurse documents in advance for a task that hasn’t been completed?
It’s considered falsification of records and can lead to disciplinary action.
How often must comprehensive resident assessments be updated?
At least every 90 days or when there is a significant change in condition.
What format is commonly used for writing progress notes?
SOAP format – Subjective, Objective, Assessment, Plan.
SOAPIE - Subjective, Objective, Assessment, Plan, Intervention, Evaluation.
How should changes in a resident’s condition affect their care plan?
The care plan must be updated immediately to reflect the changes.
What should you do if you make an error in documentation?
Draw a single line through the error, label it as an error, and initial/date it. Strike out in EMR.
What is a common mistake when using abbreviations in documentation?
Using unapproved or ambiguous abbreviations.
What tool is commonly used to document assessments in long-term care?
Minimum Data Set (MDS).
When can progress notes include personal opinions about the resident?
NEVER. Progress notes should be factual and objective.
Who should be involved in developing and updating a resident’s care plan?
The interdisciplinary team, including the nurse, physician, social worker, dietitian, and family.
How long must nursing documentation be retained for legal compliance?
Retention requirements vary by state, but typically 5-10 years.
Why is it risky to copy and paste previous documentation into a new record?
It can lead to errors and outdated information being included.
What is the primary purpose of the Minimum Data Set (MDS) in long-term care documentation?
To assess a resident's functional capabilities and help develop an individualized care plan.
What should be included in progress notes when documenting a resident’s fall?
Time and location of the fall, witnessed or unwitnessed, resident's condition after the fall, interventions, and notifications made to family/physician.
What must a care plan include for residents with dementia to ensure person-centered care?
Specific strategies to address behavioral symptoms, communication needs, and activities based on the resident’s preferences.
What are the consequences of incomplete or missing documentation during a regulatory audit?
Fines, citations, loss of licensure, or decreased facility ratings and funding.
Why is it important to avoid documenting subjective assumptions about a resident’s behavior?
Assumptions can lead to bias and may not accurately reflect the resident’s condition, impacting care and legal documentation.
When documenting a wound assessment, what specific elements must be included?
Location, size, color, presence of drainage, odor, and any signs of infection.
How can a nurse ensure progress notes meet professional and legal standards?
By using objective language, documenting in real-time, avoiding vague terms, being thorough yet concise, and ensuring accuracy.)
What documentation is necessary to demonstrate the effectiveness of a care plan?
Ongoing evaluation notes detailing the resident's progress toward goals and any necessary revisions to interventions.
Why is HIPAA compliance critical in nursing documentation, and how can it be maintained?
To protect resident privacy and confidentiality. It is maintained by not sharing passwords, logging out of systems, and ensuring documents are stored securely.
What is a common risk of documenting “status unchanged” in a resident’s chart?
It fails to provide sufficient detail about the resident's current condition and progress, potentially leading to gaps in care.