Documentation and Record Keeping Flashcards

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

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

A complete STRTP case file must include the admission agreement, signed personal rights form, ISP, health records, and other required documentation.

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

Answer: 30 days

California licensing regulations require that an initial ISP be completed within 30 days of a resident's admission to the STRTP.

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

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

Clinical progress notes in STRTPs should follow structured formats like DAP or SOAP to ensure consistency, clarity, and clinical usefulness.

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

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

California regulations require community care facilities to retain resident records for at least 7 years after discharge or until the individual turns 28, whichever is longer.

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

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

Complete medication administration records must include the drug name, dosage, time, route, and the signature of the staff member who administered it.

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

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

Incident reports written by those with direct knowledge are more accurate, credible, and useful for clinical review and regulatory compliance.