Documenting Nursing Activities (Record System Used in an Agency)
Documenting Nursing Activities (Record System Used in an Agency) ( 27 Questions)
A nurse is documenting the care provided to a client who receives home health services.
Which of the following records should the nurse use to certify that the client meets Medicare eligibility criteria and to outline the services to be provided?
Home health certification and plan of treatment. This is the record that the nurse uses to certify that the client meets Medicare eligibility criteria and to outline the services to be provided. A home health certification and plan of treatment is a document that contains the physician’s or allowed practitioner’s orders for home health services, the patient’s diagnosis, the patient’s functional limitations, the type and amount of services needed, and the expected duration of care.
Outcome and Assessment Information Set (OASIS) is a standardized assessment tool that HHAs use to collect data on adult patients receiving skilled services.
OASIS is not used to certify eligibility or plan treatment.
Home care flow sheet is a form that HHAs use to document the daily care provided by nurses and home health aides.
A home care flow sheet does not certify eligibility or plan treatment.
Home care progress note is a form that HHAs use to document the patient’s progress toward the goals of care, any changes in the plan of care, and any communication with other health care providers.
A home care progress note does not certify eligibility or plan treatment.
Home health certification and plan of treatment. This is the record that the nurse uses to certify that the client meets Medicare eligibility criteria and to outline the services to be provided. A home health certification and plan of treatment is a document that contains the physician’s or allowed practitioner’s orders for home health services, the patient’s diagnosis, the patient’s functional limitations, the type and amount of services needed, and the expected duration of care.
Choice B is wrong because Outcome and Assessment Information Set (OASIS) is a standardized assessment tool that HHAs use to collect data on adult patients receiving skilled services.
OASIS is not used to certify eligibility or plan treatment.
Choice C is wrong because Home care flow sheet is a form that HHAs use to document the daily care provided by nurses and home health aides.
A home care flow sheet does not certify eligibility or plan treatment.
Choice D is wrong because Home care progress note is a form that HHAs use to document the patient’s progress toward the goals of care, any changes in the plan of care, and any communication with other health care providers.
A home care progress note does not certify eligibility or plan treatment.