Gerontological Nursing & Healthy Aging, 6th Edition- Chapter 08
1. Which of the following is a true statement about documentation?
a. Nurses should keep records of clients' wishes.
b. Clients do not have access to their own medical records.
c. The Outcomes and Assessment Information Set (OASIS) is a complete
record of the health status of a client.
d. The nurse is responsible for completing all of the Minimum Data Set (MDS).-
: ANS: A
Entering clients' expressed wishes in the medical or clinical record helps ensure
that the interdisciplinary team respects these wishes. According to regulations after
the enactment of the Health Insurance Portability and Accountability Act (HIPAA),
the client has access to his or her own medical records and may designate others
to have access. The OASIS is used to measure outcomes for quality improvement
purposes; it does not contain all of the necessary information for care, such as vital
signs. The MDS should be completed jointly by all members of the interdisciplinary
team.
2. Which one of the following is connected with the nursing home reform
mandated by a 1987 law?
a. Resident Assessment Instrument (RAI)
b. HIPAA
c. OASIS
d. Fulmer SPICES: ANS: A
The RAI must be completed for all residents receiving Medicare or Medicaid. The
HIPAA was passed in 1996 and mandates privacy practices. The OASIS is an
assessment designed for use in the home health care setting. Fulmer SPICES is
an overall assessment tool developed in 2007.
3. An older adult client has diabetes mellitus and requires hemodialysis for
, renal failure. The client is discharged to home to recover from a sternal wound
infection and coronary artery bypass graft surgery (CABG). A home care nurse
will provide wound care. Which of the following is the major justification for
the complete and accurate documentation of this client's care?
a. Requires complex health care
b. Has needs in multiple settings
c. Is at risk for iatrogenic problems
d. Has significant health care expenses: ANS: A
The major reason that documentation of this client's health care must be accurate
and complete is that she has complex health care needs in multiple settings and
experiences a high risk for iatrogenic problems and high reimbursement expenses.
The duration of her care is likely to be lengthy; the sternal wound infection after
CABG is serious because of the potential for sternal osteomyelitis. In addition,
individuals with diabetes are at high risk for infection and are slow to heal. The
complexity of the care includes receiving care in multiple settings—at home, at
dialysis, and in primary care for post discharge follow-up care. For an older adult
with diabetes, coronary artery disease, renal failure, and a serious infection, each
facet of health care depends on complete and accurate data on the other aspects
of her care to help her achieve optimal health and wellness. This older adult is at
risk for iatrogenic problems because of the complexity of care. Each type of care,
each illness or condition, and each setting exposes this older adult to a separate set
of risks. In addition, individuals with diabetes can have peripheral neuropathies that
increase the risk for falls and injuries. This older adult incurs health care expenses
dealing with complex health care requirements including a recent hospital stay for
surgery and complicated by an infection, ongoing needs for hemodialysis, and home
care. Because much of the care is nurse driven, documentation is the basis for which
reimbursement is provided.
4. Which documentation tool does the nurse use to achieve optimal functional
1. Which of the following is a true statement about documentation?
a. Nurses should keep records of clients' wishes.
b. Clients do not have access to their own medical records.
c. The Outcomes and Assessment Information Set (OASIS) is a complete
record of the health status of a client.
d. The nurse is responsible for completing all of the Minimum Data Set (MDS).-
: ANS: A
Entering clients' expressed wishes in the medical or clinical record helps ensure
that the interdisciplinary team respects these wishes. According to regulations after
the enactment of the Health Insurance Portability and Accountability Act (HIPAA),
the client has access to his or her own medical records and may designate others
to have access. The OASIS is used to measure outcomes for quality improvement
purposes; it does not contain all of the necessary information for care, such as vital
signs. The MDS should be completed jointly by all members of the interdisciplinary
team.
2. Which one of the following is connected with the nursing home reform
mandated by a 1987 law?
a. Resident Assessment Instrument (RAI)
b. HIPAA
c. OASIS
d. Fulmer SPICES: ANS: A
The RAI must be completed for all residents receiving Medicare or Medicaid. The
HIPAA was passed in 1996 and mandates privacy practices. The OASIS is an
assessment designed for use in the home health care setting. Fulmer SPICES is
an overall assessment tool developed in 2007.
3. An older adult client has diabetes mellitus and requires hemodialysis for
, renal failure. The client is discharged to home to recover from a sternal wound
infection and coronary artery bypass graft surgery (CABG). A home care nurse
will provide wound care. Which of the following is the major justification for
the complete and accurate documentation of this client's care?
a. Requires complex health care
b. Has needs in multiple settings
c. Is at risk for iatrogenic problems
d. Has significant health care expenses: ANS: A
The major reason that documentation of this client's health care must be accurate
and complete is that she has complex health care needs in multiple settings and
experiences a high risk for iatrogenic problems and high reimbursement expenses.
The duration of her care is likely to be lengthy; the sternal wound infection after
CABG is serious because of the potential for sternal osteomyelitis. In addition,
individuals with diabetes are at high risk for infection and are slow to heal. The
complexity of the care includes receiving care in multiple settings—at home, at
dialysis, and in primary care for post discharge follow-up care. For an older adult
with diabetes, coronary artery disease, renal failure, and a serious infection, each
facet of health care depends on complete and accurate data on the other aspects
of her care to help her achieve optimal health and wellness. This older adult is at
risk for iatrogenic problems because of the complexity of care. Each type of care,
each illness or condition, and each setting exposes this older adult to a separate set
of risks. In addition, individuals with diabetes can have peripheral neuropathies that
increase the risk for falls and injuries. This older adult incurs health care expenses
dealing with complex health care requirements including a recent hospital stay for
surgery and complicated by an infection, ongoing needs for hemodialysis, and home
care. Because much of the care is nurse driven, documentation is the basis for which
reimbursement is provided.
4. Which documentation tool does the nurse use to achieve optimal functional
