Illinois Nursing Home Administrators (NHA) Practice Exam

Which of the following does NOT need to be included in a resident's medical record?

1. Diagnoses

2. Lab test results

3. Record of any prescription and non-prescription medications taken in the 30 days prior to admission

4. Payor source

The correct answer is: Payor source

In the context of nursing home administration and resident medical records, including a payor source is not typically part of the clinical documentation that forms the core of a resident's medical history and treatment plan. The primary focus of medical records is to document the clinical aspects of a resident's care, which involves medical diagnoses, lab test results, and a detailed account of medications taken prior to admission. Diagnoses provide the foundation for care planning and treatment, enabling healthcare providers to understand the medical conditions being addressed. Lab test results serve as critical indicators of a resident’s health status and inform ongoing clinical decisions. Records of medications taken before admission are essential for ensuring continuity of care and avoiding potential drug interactions or duplications. In contrast, the payor source pertains more to billing and administrative aspects rather than patient care. While it is important for operational purposes, it does not affect the clinical management of the resident and therefore does not need to be included in the medical record itself. This distinction helps emphasize the importance of maintaining accurate clinical documentation focused specifically on health care delivery.