Illinois Nursing Home Administrators (NHA) Practice Exam

What is the required action after a resident's visit to a physician?

1. No note by the physician is necessary for the facility's medical record for the resident

2. The physician shall record the result in a note that is added to the facility's medical record for the resident

3. Physician's visits may be conducted only at the facility, requiring a note at each visit

4. Only verbal communication from the physician is required

The correct answer is: The physician shall record the result in a note that is added to the facility's medical record for the resident

Recording the results of a physician's visit in the facility's medical record for the resident is crucial for maintaining a comprehensive and accurate health history. This ensures that any changes in the resident's condition, treatment plans, or additional care needs are documented and accessible to all members of the care team. Having a physician record their findings in a note serves multiple purposes: it formalizes communication about the resident's health status, enhances continuity of care, and provides legal documentation that can be vital in case of disputes regarding treatment or care levels. The documentation helps other healthcare providers in the facility stay informed and makes it easier to track treatment effectiveness and respond to any emerging health issues. While physician visits can occur in various settings and communication methods can be diverse, the requirement for a formal note in the resident's medical record is standard practice that prioritizes safety and accountability in healthcare provision. This approach supports coordinated care and ensures that all relevant information is shared among the healthcare team involved in the resident's care.