STRTP Documentation and Record Keeping

Question 1

California STRTP regulations require that a resident's case file contain which of the following core documents?

Accepted Answer

Admission agreement, personal rights acknowledgment, Individualized Service Plan, and health records

Answer

Only the admission agreement and emergency contact list

Answer

Only the Individualized Service Plan and discharge summary

Answer

Only medical records and insurance information

Question 2

An Individualized Service Plan (ISP) in an STRTP must be developed within how many days of a resident's admission?

Accepted Answer

30 days

Answer

7 days

Answer

60 days

Answer

90 days

Question 3

In an STRTP, progress notes in a resident's file should be written using which documentation standard?

Accepted Answer

DAP (Data-Assessment-Plan) or SOAP (Subjective-Objective-Assessment-Plan) format

Answer

A narrative paragraph with no specific format

Answer

Bullet points without clinical assessment

Answer

A checklist format approved by the administrator only

Question 4

How long must an STRTP retain a former resident's records after discharge in California?

Accepted Answer

Until the former resident reaches age 28, or for a minimum of 7 years, whichever is longer

Answer

For 1 year after discharge

Answer

For 3 years after discharge

Answer

Until the placing agency requests destruction

Question 5

Which of the following must be documented immediately following any medication administration in an STRTP?

Accepted Answer

The medication name, dose, time, route of administration, and the staff member's signature

Answer

Only the medication name and resident's name

Answer

A general note that medications were given during the shift

Answer

Documentation is only required for psychotropic medications

Question 6

STRTP incident reports must be written by the staff member most directly involved in or aware of the incident because:

Accepted Answer

First-hand accounts provide the most accurate and legally defensible record of what occurred

Answer

It serves as a form of disciplinary documentation for the staff member

Answer

Second-hand reports are not allowed under any circumstances

Answer

The administrator must review and approve the report before any information is recorded