A client in long-term care is scheduled for a review of the assessment and care screening process. This assessment will be documented in which of the following?
1. Minimum Data Set (MDS)
2. Omnibus Budget Reconciliation Act (OBRA)
3. Charting by exception (CBE)
4. Kardex
1. Minimum Data Set (MDS)
Rationale:
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. It is under the OBRA law that the MDS is identified. With charting by exception (CBE) only abnormal or significant findings or exceptions to norms are recorded. The Kardex is a system of organizing client information so it can be accessed quickly and is usually used in the acute care area.
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