California Nursing Home Administrator License Practice Exam

If a resident has a health care surrogate, where must this information be documented?

1. In the resident record

2. On the admission/discharge log

3. In a major incident log

4. On the medication observation record

The correct answer is: In the resident record

The proper documentation of a resident's health care surrogate is essential for ensuring that care decisions are aligned with the resident's wishes. Recording this information in the resident record allows for quick and easy access to important details regarding who is authorized to make health care decisions on behalf of the resident if they are unable to do so themselves. It is crucial for staff and medical personnel to have this information readily available to respect the resident's rights and to follow the appropriate legal protocols in managing their care. The resident record serves as a comprehensive account of the individual’s health status, preferences, and directives, which is fundamental for providing quality care. Documentation in other options, such as the admission/discharge log or major incident log, does not serve the purpose of ensuring immediate access to details about health care surrogates for treatment decisions. Similarly, the medication observation record is specifically designed for tracking medication administration and interactions, not for documenting surrogate decision-making authority. Therefore, placing this information in the resident record is the most effective method for ensuring that all care providers are informed and can act in accordance with the resident’s preferences.