Documentation & Health Records Flashcards

On the MDS 3.0, which item records a resident's weight loss of 5% or more in the last month or 10% or more in the last 6 months?

Answer: K0300

K0300 captures weight loss meeting the 5%/30-day or 10%/180-day thresholds.

A dietitian discovers an error in a signed paper progress note. What is the correct way to fix it?

Answer: Draw a single line through the error, write the correction, and initial and date it

A single line keeps the original entry readable and preserves the legal integrity of the record.

Which component of an ADIME note holds the PES statement?

Answer: Diagnosis

The nutrition diagnosis step is documented as a Problem, Etiology, Signs/Symptoms statement.

Under the RAI process, the comprehensive care plan must be completed within how many days after the admission MDS assessment is completed?

Answer: 7 days

CMS requires the comprehensive care plan within 7 days after the comprehensive assessment is completed.

Which ICD-10-CM code represents severe protein-calorie malnutrition?

Answer: E43

E43 is unspecified severe protein-calorie malnutrition; E44.0 is moderate and E44.1 is mild.

A resident chooses to keep eating regular-texture food despite a speech-language pathologist's recommendation for minced and moist. What should the dietitian's documentation include?

Answer: The informed refusal: risks explained, the resident's understanding and choice, and the care plan update

Documenting informed choice and risk education protects the resident's autonomy and the facility.

Under the Joint Commission 'Do Not Use' list, which abbreviation must not appear in a diet or supplement order?

Answer: QD

QD is easily mistaken for QID, so 'daily' must be written out.