A client in long-term care is scheduled for a review of the assessment and care screening process. Where should the nurse document this information?
1. MDS
2. OBRA
3. CBE
4. Kardex
Correct Answer: 1
Rationale 1: The Minimum Data Set (MDS) for assessment and care screening must be performed within 4 days of a client's admission to a long-term care facility and reviewed every 3 months. Laws influencing the kind and frequency of documentation required are the Health Care Financing Administration and the Omnibus Budget Reconciliation Act (OBRA) of 1987.
Rationale 2: Laws influencing the kind and frequency of documentation required are the Health Care Financing Administration and the Omnibus Budget Reconciliation Act (OBRA) of 1987.
Rationale 3: CBE stands for charting by exception and is not the form of documentation used for this type of assessment.
Rationale 4: Kardex is a system of organizing client information so it can be accessed quickly. It is usually used in the acute care area.
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