CSG Documentation & Health Records 5

Question 1

In a SOAP note, where would a dietitian record a resident's report that 'food tastes bland'?

Accepted Answer

Subjective

Answer

Statements reported by the resident or family belong in the Subjective section.

Question 2

Which of these is the best-written nutrition PES statement?

Accepted Answer

Inadequate oral intake related to dysphagia as evidenced by intake of less than 50% of meals for 7 days

Answer

A good PES statement names a nutrition problem, a specific cause, and measurable signs or symptoms.

Question 3

When no state law applies, federal rules (42 CFR 483.70) require a nursing facility to keep resident clinical records for an adult for how long after discharge?

Accepted Answer

5 years

Answer

Federal regulation requires keeping adult resident records for 5 years from discharge when no state requirement exists.

Question 4

A dietitian copies and pastes last week's assessment into today's note without changes. What is the main documentation risk?

Accepted Answer

Outdated or wrong information is carried forward, weakening the record's accuracy and legal defensibility

Answer

Cloned documentation can spread errors and may not reflect the resident's current status.

Question 5

Which document is a set of actionable medical orders on life-sustaining treatment, including artificial nutrition, that follows the patient across care settings?

Accepted Answer

POLST/MOLST form

Answer

POLST forms are signed medical orders that cover preferences such as tube feeding and transfer between settings.

CSG - Certified Specialist in Gerontological Nutrition Practice Test

CSG - Certified Specialist in Gerontological Nutrition Practice Test

CSG Documentation & Health Records 5