Which documentation tool does the nurse use to achieve optimal functional status for a nursing home resident?
a. Narrative patient progress notes
b. Problem-oriented documentation
c. Resource Utilization Group (RUG)
d. Resident Assessment Instrument (RAI)
D
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A Incorrect. Narrative progress notes are used in nursing homes to describe events that are unsuitable for other forms of documentation in the medical record.
B Incorrect. Problem-oriented documentation identifies resident problems, the plan of care to resolve the problem, and the outcome of the problem or response to treatment.
C Incorrect. The RUG is the reimbursement tool in the RAI.
D Correct. Mandated by the federal government to improve the quality of care for nursing home residents, the nurse uses the RAI to help residents in nursing homes achieve optimal functional status. The RAI includes identification of is-sues with the Minimum Data Set, a comprehensive assessment from Resident Assessment Protocols, and the foundation for reimbursement using the Resource Utilization Group.
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