General CNA Practice CNA Practice Documentation and Reporting 1 — Questions and Answers
Question 1: When should a CNA document care provided to a resident?
- After completing the care (Correct answer)
- Before starting the care
- At the end of the shift only
- When the supervisor requests it
Correct answer: After completing the care
Documentation must occur after care is provided to accurately reflect what was actually done.
Question 2: Which abbreviation is commonly used in medical records to mean 'as needed'?
- PRN (Correct answer)
- QID
- STAT
- NPO
Correct answer: PRN
PRN (from Latin 'pro re nata') means 'as needed' and indicates care or medication given only when a specific condition arises.
Question 3: What is the FIRST action a CNA should take when noticing a change in a resident's condition?
- Report the change to the nurse immediately (Correct answer)
- Document the change in the medical record
- Call the resident's family
- Wait to see if the condition improves on its own
Correct answer: Report the change to the nurse immediately
A change in condition must be reported to the nurse immediately so appropriate assessment and intervention can occur without delay.
Question 4: Which of the following is the correct way to correct a documentation error in a paper medical record?
- Draw a single line through the error, write 'error,' initial, and date it (Correct answer)
- Use correction fluid (white-out) to cover the mistake
- Erase the error completely so it cannot be read
- Tear out the page and rewrite the entry
Correct answer: Draw a single line through the error, write 'error,' initial, and date it
A single line through the error preserves the original entry for legal purposes while clearly marking it as incorrect.
Question 5: What is the primary purpose of an incident report?
- To document unexpected events in order to improve safety and prevent recurrence (Correct answer)
- To assign blame and punish the staff member responsible
- To notify the resident's family about all problems
- To cancel the resident's existing care plan
Correct answer: To document unexpected events in order to improve safety and prevent recurrence
Incident reports document unexpected events to identify patterns, improve facility safety, and prevent future occurrences.
Question 6: Which of the following is an example of objective data when documenting a resident's condition?
- Temperature reading of 101.2°F (Correct answer)
- Resident appears to be in pain
- Resident seems anxious today
- Resident looks pale to staff
Correct answer: Temperature reading of 101.2°F
Objective data is measurable and observable with a tool or instrument, such as a specific temperature reading, rather than a subjective interpretation.
Question 7: A resident refuses to have their blood pressure taken. How should the CNA document this?
- Record that the resident refused the procedure and the time it occurred (Correct answer)
- Skip documentation since the procedure was not completed
- Write 'unable to perform' without any further explanation
- Document an estimated reading based on prior values
Correct answer: Record that the resident refused the procedure and the time it occurred
Refusals must be accurately documented so the care team is informed and legal accountability is maintained.
General CNA Practice CNA Practice Documentation and Reporting 1
When should a CNA document care provided to a resident?