Chapter 08: Recognizing and Analyzing Cues in Gerontological Nursing Touhy: Ebersole and Hess’ Gerontological Nursing & Healthy Aging, 6th Edition Que $ Ans
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Ebersole & Hess Healthy Aging
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Ebersole & Hess Healthy Aging
Which of the following is a true statement about documentation?
a. Nurses should keep records of clients' wishes.
b. Clients do not have access to their own medical records.
c. The Outcomes and Assessment Information Set (OASIS) is a complete record of the health status of a client.
d. The nu...
Chapter 08: Recognizing and Analyzing
Cues in Gerontological Nursing Touhy:
Ebersole and Hess’ Gerontological
Nursing & Healthy Aging, 6th Edition Que
$ Ans
Which of the following is a true statement about documentation?
a. Nurses should keep records of clients' wishes.
b. Clients do not have access to their own medical records.
c. The Outcomes and Assessment Information Set (OASIS) is a complete record of the health
status of a client.
d. The nurse is responsible for completing all of the Minimum Data Set (MDS). - ANS ANS:
A
Entering clients' expressed wishes in the medical or clinical record helps ensure that the
interdisciplinary team respects these wishes. According to regulations after the enactment of the
Health Insurance Portability and Accountability Act (HIPAA), the client has access to his or her
own medical records and may designate others to have access. The OASIS is used to measure
outcomes for quality improvement purposes; it does not contain all of the necessary information
for care, such as vital signs. The MDS should be completed jointly by all members of the
interdisciplinary team.
Which one of the following is connected with the nursing home reform mandated by a 1987 law?
a. Resident Assessment Instrument (RAI)
b. HIPAA
c. OASIS
d. Fulmer SPICES - ANS ANS: A
The RAI must be completed for all residents receiving Medicare or Medicaid. The HIPAA was
passed in 1996 and mandates privacy practices. The OASIS is an assessment designed for use
in the home health care setting. Fulmer SPICES is an overall assessment tool developed in
2007.
An older adult client has diabetes mellitus and requires hemodialysis for renal failure. The client
is discharged to home to recover from a sternal wound infection and coronary artery bypass
, graft surgery (CABG). A home care nurse will provide wound care. Which of the following is the
major justification for the complete and accurate documentation of this client's care?
a. Requires complex health care
b. Has needs in multiple settings
c. Is at risk for iatrogenic problems
d. Has significant health care expenses - ANS ANS: A
The major reason that documentation of this client's health care must be accurate and complete
is that she has complex health care needs in multiple settings and experiences a high risk for
iatrogenic problems and high reimbursement expenses. The duration of her care is likely to be
lengthy; the sternal wound infection after CABG is serious because of the potential for sternal
osteomyelitis. In addition, individuals with diabetes are at high risk for infection and are slow to
heal. The complexity of the care includes receiving care in multiple settings—at home, at
dialysis, and in primary care for post discharge follow-up care. For an older adult with diabetes,
coronary artery disease, renal failure, and a serious infection, each facet of health care depends
on complete and accurate data on the other aspects of her care to help her achieve optimal
health and wellness. This older adult is at risk for iatrogenic problems because of the complexity
of care. Each type of care, each illness or condition, and each setting exposes this older adult to
a separate set of risks. In addition, individuals with diabetes can have peripheral neuropathies
that increase the risk for falls and injuries. This older adult incurs health care expenses dealing
with complex health care requirements including a recent hospital stay for surgery and
complicated by an infection, ongoing needs for hemodialysis, and home care. Because much of
the care is nurse driven, documentation is the basis for which reimbursement is provided.
Which documentation tool does the nurse use to achieve optimal functional status for a nursing
home resident?
a. Narrative client progress notes
b. Problem-oriented documentation
c. Resource Utilization Group (RUG)
d. Resident Assessment Instrument (RAI) - ANS ANS: D
Mandated by the federal government to improve the quality of care for nursing home residents,
the nurse uses the RAI to help residents in nursing homes achieve optimal functional status.
The RAI includes identification of issues with the MDS, a comprehensive assessment from
Resident Assessment Protocols (RAPs), and the foundation for reimbursement using the RUG.
Narrative progress notes are used in nursing homes to describe events that are unsuitable for
other forms of documentation in the medical record. Problem-oriented documentation identifies
resident problems, the plan of care to resolve the problem, and the outcome of the problem or
response to treatment. The RUG is the reimbursement tool in the RAI.
Using the Resident Assessment Instrument (RAI), the nurse identifies a trigger for a male
nursing home resident who requires an indwelling urinary catheter from the Minimum Data Set
(MDS). Which should the nurse do next?
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