CMT Documentation and Reporting 2 — Questions and Answers
Question 1: A resident refuses their scheduled medication. What must the medication technician document?
- The refusal, reason given, and nurse notified (Correct answer)
- Only that the medication was not given
- The refusal and a plan to give it later
- Nothing, since the resident refused
Correct answer: The refusal, reason given, and nurse notified
Refusals must be documented with the reason stated by the resident and notification to the supervising nurse.
Question 2: Which abbreviation is on the Joint Commission's 'Do Not Use' list due to misinterpretation risk?
- mg
- mL
- U (for units) (Correct answer)
- tab
Correct answer: U (for units)
'U' for units is prohibited because it can be misread as '0' or '4,' leading to dangerous dosing errors.
Question 3: After giving a PRN medication, what additional documentation is required compared to a routine medication?
- The resident's response or effectiveness must be recorded (Correct answer)
- A physician co-signature is required
- The route must be documented twice
- Nothing additional is required
Correct answer: The resident's response or effectiveness must be recorded
PRN medications require follow-up documentation of the resident's response to assess whether the medication was effective.
Question 4: A medication technician notices a discrepancy between the MAR and the medication bottle label. What is the correct action?
- Withhold the medication and report to the nurse immediately (Correct answer)
- Give the medication listed on the bottle
- Correct the MAR to match the bottle
- Give whichever dose is lower for safety
Correct answer: Withhold the medication and report to the nurse immediately
Any discrepancy between the MAR and medication label must be reported to the nurse before administration to prevent errors.
Question 5: What does the term 'late entry' mean in medical documentation?
- A note added after the fact to record information that was omitted at the time of care (Correct answer)
- An entry written past the facility's shift-change deadline
- A notation that a medication was given late
- Documentation written by the oncoming shift nurse
Correct answer: A note added after the fact to record information that was omitted at the time of care
A late entry is a properly labeled addendum added to the record when documentation was accidentally omitted during the care event.
Question 6: Which of the following is the correct way to correct a handwritten error on a paper MAR?
- Draw a single line through the error, initial, and date it (Correct answer)
- Use correction fluid to cover the mistake neatly
- Erase the error completely before rewriting
- Cross out with multiple lines so it is unreadable
Correct answer: Draw a single line through the error, initial, and date it
A single line through the error, with initials and date, keeps the original entry legible and meets legal documentation standards.
Question 7: A medication technician administered a medication to the wrong resident. After ensuring the resident's safety, what is the FIRST documentation step?
- Complete an incident or occurrence report (Correct answer)
- Delete the entry from the MAR
- Document on the MAR that no error occurred
- Wait for the nurse to document the event
Correct answer: Complete an incident or occurrence report
An incident/occurrence report must be completed promptly to initiate facility follow-up and protect resident safety.
CMT Documentation and Reporting 2
A resident refuses their scheduled medication.
What must the medication technician document?