Illinois Nursing Home Administrators (NHA) Practice Exam

Notes about significant developments in a resident's response to care are included in which document?

1. Care plan

2. Medical history form

3. Medical record

4. Policy and procedure manuals

The correct answer is: Medical record

The correct answer is found in the medical record, which serves as a comprehensive document that thoroughly captures all relevant information regarding a resident's health and care. This includes significant developments, changes in condition, responses to treatments, and other critical observations made by healthcare professionals. The medical record is essential for ongoing care as it provides a complete picture of the resident's health status and ensures continuity of care among different team members. In contrast, the care plan outlines specific goals and strategies for the resident's care but does not typically include detailed notes about the response to treatments or changes in condition. The medical history form contains background information about the resident’s past medical issues but does not record day-to-day observations. Policy and procedure manuals are used to guide the operations and practices within the facility and do not pertain to individual residents’ responses to care.