CSG Documentation & Health Records 2

Question 1

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?

Accepted Answer

K0300

Answer

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

Question 2

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

Accepted Answer

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

Answer

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

Question 3

Which component of an ADIME note holds the PES statement?

Accepted Answer

Diagnosis

Answer

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

Question 4

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

Accepted Answer

7 days

Answer

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

Question 5

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

Accepted Answer

E43

Answer

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

CSG - Certified Specialist in Gerontological Nutrition Practice Test