Evaluation & Documentation Flashcards
7 cards from real ACC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Evaluation & Documentation flashcards as text
During a care conference, the nursing team reports a resident has experienced a decline in cognition. How should the activity professional respond regarding documentation?
Answer: Review and update the activity assessment and care plan to reflect the cognitive change
A change in cognitive status triggers a reassessment and care plan update to ensure programming remains appropriate for the resident's current abilities.
Which practice BEST supports accurate attendance documentation in an activity program?
Answer: Documenting attendance immediately following each program using real-time records
Real-time documentation immediately after each program ensures accuracy and provides a timely record of resident participation.
Which of the following is an example of a non-measurable activity goal that should be revised?
Answer: Resident will enjoy activities more
'Will enjoy activities more' is subjective and non-measurable; effective goals must define specific, observable, and quantifiable outcomes.
A surveyor reviewing activity records asks for documentation demonstrating individualized programming. The BEST evidence would be:
Answer: Individualized care plans with goals tied to each resident's assessed interests and functional level
Individualized care plans linked to assessed interests and functional abilities are the primary evidence of person-centered, individualized activity programming.
Which scenario BEST illustrates the use of a 'significant change assessment' in activity documentation?
Answer: A resident is diagnosed with a new stroke, requiring reassessment of activity needs
A new diagnosis such as a stroke represents a significant change in condition that triggers a comprehensive reassessment of the resident's activity needs and care plan.
In the SOAP documentation format used by some interdisciplinary teams, what does the 'O' represent?
Answer: Observations (Objective data)
In SOAP (Subjective, Objective, Assessment, Plan), 'O' represents Objective data — measurable, observable information such as attendance, behavior, and functional performance.
Which of the following BEST describes the purpose of an activity department audit or program evaluation?
Answer: To systematically review documentation, programming outcomes, and compliance to improve quality of care
A program evaluation systematically reviews documentation accuracy, goal achievement, and regulatory compliance to identify areas for quality improvement.