CMT - Certified Medical Technician Medical Records and Charting Questions and Answers 1

Question 1

A CMT makes an error while documenting in a resident's paper chart. What is the legally acceptable method for correcting this mistake?

Accepted Answer

Draw a single line through the error, write "error" above it, and add the CMT's initials and the date.

Answer

Use correction fluid to cover the error completely and write the correct information over it.

Answer

Scribble over the incorrect entry until it is unreadable and write the correct information nearby.

Answer

Leave the error as is and add a correct entry on the next available line in the chart.

Question 2

A resident tells the CMT, "My stomach feels like it's on fire." Which of the following is the most appropriate and accurate way to document this statement in the medical record?

Accepted Answer

Resident states, "My stomach feels like it's on fire."

Answer

Resident has severe heartburn.

Answer

Resident is complaining of gastrointestinal distress.

Answer

Resident appears to be in significant pain from their stomach.

Question 3

After a resident refuses their scheduled blood pressure medication, and the charge nurse has been notified, what is the CMT's primary documentation responsibility?

Accepted Answer

Document the refusal on the MAR, note the reason for refusal if given, and record that the nurse was notified.

Answer

Leave the medication administration record (MAR) blank for that time slot.

Answer

Persuade the resident to take the medication and then chart it as given.

Answer

Chart the medication as 'held' without providing any additional context or reason.

Question 4

Which of the following is an unacceptable practice when documenting in a medical record due to the high risk of medication errors?

Accepted Answer

Using the abbreviation "U" for "unit" when documenting an insulin dose.

Answer

Writing out "international unit" instead of using an abbreviation.

Answer

Documenting "0.5 mg" instead of ".5 mg".

Answer

Using military time (e.g., 14:00) for entries.

Question 5

A CMT administers a PRN (as needed) pain medication to a resident at 10:00. According to best practices, what is the correct procedure for documenting this event?

Accepted Answer

Chart that the medication was given immediately at 10:00, and then make a follow-up entry documenting the resident's response later.

Answer

Document both the administration and the resident's response to it at the end of the shift.

Answer

Wait until the resident states they have relief before documenting the administration.

Answer

Document the administration at 10:00 and assume the medication was effective unless the resident complains again.

Question 6

When completing a charting entry in a resident's medical record, which of the following is essential for the entry to be considered legally valid?

Accepted Answer

The entry must include the date, time, and the CMT's legible signature and professional title.

Answer

The entry must be co-signed by the supervising nurse.

Answer

The entry must be written in blue ink only.

Answer

The entry must be reviewed by the facility administrator within 24 hours.