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.

Outcome and assessment information set.

Home care flow sheet.

Home care progress note.

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is C

Explanation

Medication administration record.

A medication administration record (MAR) is a document that records the medications that have been given to a patient, including the dose, route, time, and nurse’s initials.

A MAR is an essential part of nursing documentation and ensures safe and accurate medication administration.

Choice A is wrong because a graphic record is a document that shows the trends of vital signs, intake and output, weight, and other measurements over time.

A graphic record does not include information about medications.

Choice B is wrong because a daily care record is a document that records the routine care activities that have been performed for a patient, such as hygiene, nutrition, elimination, mobility, and comfort measures.

A daily care record does not include information about medications.

Choice D is wrong because a client teaching record is a document that records the education that has been provided to a patient or family, such as disease process, medications, diet, exercise, self-care, and discharge planning.

A client teaching record does not include information about medication administration.

CBE documentation is a method of charting by exception that allows the nurse to document only those findings that fall outside the standard of care or norms defined by a specific institution.

CBE documentation reduces the amount of time required to document care and eliminates unnecessary or redundant information.

However, CBE documentation does not apply to medication administration, which must be documented accurately and completely for every patient.

A. Data. B. Problem. C. Focus. D. Assessment.

Correct Answer is C

Explanation

Focus.

Focus charting is a method of organizing health information in an individual’s record using nursing terminology to describe the individual’s health status and nursing actions.The focus of each entry can be a nursing diagnosis, a sign or symptom, an acute change in condition, a significant event, or a key word indicating compliance with a standard of care.

The focus charting method uses three columns: date and hour, focus, and progress notes.The progress notes are organized into data, action, and response, referred to as DAR.

Choice A is wrong because data is not the term used to begin each entry, but rather the category that describes the subjective and/or objective information supporting the stated focus.Choice B is wrong because problem is not the term used to begin each entry, but rather the nursing diagnosis or collaborative problem on the plan of care.Choice D is wrong because assessment is not the term used to begin each entry, but rather the phase of the nursing process that involves collecting data.

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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?

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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?