Documentation & Health Records Flashcards

How often must a quarterly MDS assessment be completed after the previous OBRA assessment?

Answer: No later than 92 days

Quarterly assessments are due no later than 92 days after the previous OBRA assessment's target date.

A long-stay resident has a sharp drop in intake and a decline in two or more areas that isn't expected to resolve. What assessment is required, and when?

Answer: A Significant Change in Status Assessment within 14 days of the determination

An SCSA must be completed within 14 days after the IDT determines a significant change occurred.

Which F-tag in the CMS long-term care survey guidance covers maintaining acceptable parameters of nutritional status and hydration?

Answer: F692

F692 covers nutrition and hydration status maintenance, including body weight and protein levels.

A bedbound resident can't stand for a height measurement. Which alternative should be documented as the method used?

Answer: Knee height or ulna length with a standard prediction equation

Knee-height or ulna-length estimates are validated for older adults and the method should be recorded.

Which MDS item records nutritional approaches such as a mechanically altered diet, therapeutic diet, or feeding tube, both during and before the stay?

Answer: K0520

K0520 captures nutritional approaches in the look-back periods before and during the stay.

Which IDDSI level describes 'minced and moist' food, and should be written as such in a diet order?

Answer: Level 5

IDDSI Level 5 is minced and moist; Level 4 is pureed and Level 6 is soft and bite-sized.

When a hospice resident's family asks to stop weighing them, what documentation best supports a compliant care plan?

Answer: Record the resident/family preference, the comfort-focused goals of care, and coordination with hospice in the care plan

Unavoidable weight loss and comfort goals must be supported by documented preferences and IDT coordination.