Ohio Nursing Home Administrator Practice Exam

What information should medical records of each resident in a nursing home contain?

1. Personal contact information

2. Dietary preferences

3. Photograph only

4. Admission record, referral record, nursing notes, care plan, resident assessment record, and more

The correct answer is: Admission record, referral record, nursing notes, care plan, resident assessment record, and more

The correct choice encompasses a comprehensive range of essential documents that are necessary for the proper management and care of residents in a nursing home. Medical records are critical for ensuring continuity of care, providing evidence-based treatment, and safeguarding residents’ health and safety. Including an admission record allows staff to have foundational information about the resident's medical history and current health status upon their entry into the facility. The referral record keeps track of any special consultations or treatments that have been recommended by other healthcare professionals. Nursing notes serve to document daily observations and care provided, which is vital for monitoring a resident’s health over time. The care plan is a personalized guide that outlines the specific needs and goals for each resident, detailing how staff will address those needs. Lastly, the resident assessment record contains essential evaluation data that aids in developing and adjusting the care plan as necessary. Together, these elements create a holistic record that reflects the comprehensive care framework the facility has established for each individual resident, ensuring they receive appropriate and responsive care.