Ace 2026-2027 Includes Frequently Tested Questions With
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1. All entries in medical records shall include ....
.- Correct Answer: 1. accurate
2. legible
3. permanently recorded
4. dated
5. authenticated with the name and title o the person making the entry.
2. Within record documentation, A rubber stamp reproduction or electronic representation
of a person's signature may be used isntead of a handwritten signature if, the
stamp/electronic representation is used only by the person who makes the entry, and
the facility possesses a statement signed by the person, certifying only that person shall
possess and use that stamp/electronic representation. --- true or false - Correct
Answer: true
3. Symbols and abbreviations may be used in medical records if approved by
____________ ___________ __________ which defines the symptoms and
abbreviations and which controls their use.
- Correct Answer: written facility policy except for persons admitted for short term care,
each resident's medical record shall contain...
,1. identification and summary sheet
2. physician's documentation
3. nursing service documentaiton
4. social service records
5. activities records
6. rehabilitative services
7. dental servicse
8. diagnostic services
9. plan of care
10. authorization or consent
4. Discharge or transfer information - Correct Answer: 1. identifiction and summary sheet
2. physician's documentation
3. nursing services documentation
4. social services records
5. activities records
6. rehabilitative services
7. dental service
8. diagnostic services
9. plan of care
10. authorization or consent
11. discharge or transfer information
5. Physician's documentation within resident's medical record must include...
1-5 - Correct Answer: 1. an admission medical evaluation by a physician or physician
extender
,2. all physician's orders
3. physician progress notes following each visit
4. annual phsycial examinations, if required
5. alternate visit schedule, and justification for such alternate visits.
6. An admission medical evaluation by a physician or physician extender for a residnet's medical
record includes... 1-5 - Correct Answer: 1. A summary of prior treatment, current medical
findings, '
2. diagnoses at the time of admission to the facility,
3. the resident's rehab potential,
4. results of physicial examination required by DHS 132.52,
5. and level of care
7. Every facility shall post in a prominentplace a notie that a resident has the right to appeal a
transfer or discahrge decision. The notice shall explain how to appeal that decision and shall
contain the address and telephone number of the nearest bureau of quality assurance regional
office. The notice shall also contain the name, address, and telephone number of the state
board on aging and long term care or if the resident is developtmentally disabled or has a
mental illness, the mailing address and telephone number of the protect and advocacy agency -
Correct Answer:
8. A copy of the notice of a residents rights to apeal a transfer or discharge decision shall be
plced in each resident's ..... - Correct Answer: admission folder
9. A resident's medical record must include all physician's orders including, when applicable,
orders concerning....
1-7 - Correct Answer: 1. admission to the facility as required by order of a physician
2. medications and treatments
3. diets
, 4. rehab services
5. limitations on activities
6. restraint orders
7. discharge or transfer
10. In a resident's medical record, needs to be nursing service documentation, which is
includes... 1-11. - Correct Answer: 1. a history and assessment of the resident's nursing
needs
2. initial care plan and the comprehensive care plan
3. nursing notes
4. nursing documentation describing the general phsycial and mental condition of the resident,
including unusual symptoms or actions, all incidents/accidents (with time, place, details of
incident/accident, action taken, and follow up care)., the administration of all medications
(including PRN medications and resident's response/ refusal to take med/omission of med/
errors in administartion of med/ and drug reactions).
5. food and fluid intake when monitoring is necessary
6. Any unusual occurences of appetite or refusale or reluctance to accept diets
7. smmary of restorative nursing measures provided.
8. summary of use of physical/chemical restraints
9. other non-routine nursing care given
10. condition of a ressident upon discharge
11. time of death, the physican called, and the person to whome the body was released.
11. Every notice of transfer or discharge to a resident, relative, re. rep. shall include a notice of
residnets rights to to appeal that decision - Correct Answer:
12. If a resident wishes to appeal a transfer or discharge decision, the resident shall send a letter
to the nearest regional office of te department's bureau of quality assurance within ____ days
after receiving the notice of transfer/discahrge from the facility, with a copy to the facility