A nurse is documenting the care provided to a client who receives home health services.
Which of the following records should the nurse use to certify that the client meets Medicare eligibility criteria and to outline the services to be provided?
Home health certification and plan of treatment.
Outcome and assessment information set.
Home care flow sheet.
Home care progress note.
The Correct Answer is A
Home health certification and plan of treatment. This is the record that the nurse uses to certify that the client meets Medicare eligibility criteria and to outline the services to be provided. A home health certification and plan of treatment is a document that contains the physician’s or allowed practitioner’s orders for home health services, the patient’s diagnosis, the patient’s functional limitations, the type and amount of services needed, and the expected duration of care.
Choice B is wrong because Outcome and Assessment Information Set (OASIS) is a standardized assessment tool that HHAs use to collect data on adult patients receiving skilled services.
OASIS is not used to certify eligibility or plan treatment.
Choice C is wrong because Home care flow sheet is a form that HHAs use to document the daily care provided by nurses and home health aides.
A home care flow sheet does not certify eligibility or plan treatment.
Choice D is wrong because Home care progress note is a form that HHAs use to document the patient’s progress toward the goals of care, any changes in the plan of care, and any communication with other health care providers.
A home care progress note does not certify eligibility or plan treatment.
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Related Questions
Correct Answer is C
Explanation
Assess the client’s understanding and readiness for discharge.
This is the first action that the nurse should take because it allows the nurse to evaluate the client’s mental status, coping skills, and educational needs.
The nurse should also explore the reasons why the client wants to go home and address any concerns or fears that the client may have.
Choice A is wrong because it is not client-centered and may increase the client’s anxiety or anger.
The nurse should not threaten or coerce the client to stay in the hospital against his will.
Choice B is wrong because it is not the priority at this time.
The nurse should first assess the client’s knowledge and willingness to undergo the cardiac catheterization before providing information about it.
Choice D is wrong because it is not the first action that the nurse should take.
The nurse should notify the physician and the charge nurse after assessing the client and documenting the findings.
A cardiac catheterization is a procedure that uses a thin, flexible tube (catheter) to access the heart and blood vessels.It can help diagnose and treat various heart conditions, such as coronary artery disease, heart valve disease, congenital heart defects, or heart failure.
Some of the benefits of cardiac catheterization are:.
• It can provide detailed information about the structure and function of the heart and blood vessels that other tests may not show.
• It can help determine the best treatment plan for the client based on his or her specific condition and needs.
• It can deliver treatments such as angioplasty, stent placement, valve repair or replacement, or device implantation during the same procedure.
• It can reduce the need for more invasive surgery or repeated hospitalizations.
Correct Answer is B
Explanation
“I should document any incident that occurs during my shift and notify the provider.” This statement indicates an understanding of the legal aspects of documentation, which include:.
• Documenting accurately, objectively, and completely to provide evidence of care delivery and support the nurse’s moral and legal responsibilities.
• Documenting any change in the patient’s condition, treatments, medications, interventions, client responses, and complaints.
• Documenting any incident that occurs during the shift and notifying the provider to ensure appropriate follow-up and prevent further harm.
• Documenting in a timely manner to minimize errors and omissions.
The other choices are wrong because:.
• Choice A is wrong because documenting only normal findings can mislead the client and other health professionals about the actual status of the client.It can also impede patient care and hinder the nurse’s legal defense in the event of a malpractice lawsuit.
• Choice C is wrong because documenting in advance can compromise the accuracy and integrity of the documentation.It can also lead to legal action if the documented events do not match the actual events.
• Choice D is wrong because documenting personal opinions about the client’s condition and care can be considered unprofessional, biased, and disrespectful.It can also damage the nurse-client relationship and expose the nurse to legal liability.
Normal ranges for documentation depend on the type of information being documented, such as vital signs, laboratory values, assessment findings, etc.
They may vary according to different sources and standards.
Nurses should follow the policies and procedures of their institution and use their clinical judgment when documenting abnormal findings.
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