Medical Records and Charting Flashcards
6 cards from real CMT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Medical Records and Charting flashcards as text
A CMT makes an error while documenting in a resident's paper chart. What is the legally acceptable method for correcting this mistake?
Answer: Draw a single line through the error, write "error" above it, and add the CMT's initials and the date.
The correct and legal procedure for correcting an error in a paper medical record is to draw a single line through the incorrect entry so that it remains legible, then write "error" or "mistaken entry" nearby, and add the date, time, and initials of the person making the correction. This maintains the integrity of the legal document.
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?
Answer: Resident states, "My stomach feels like it's on fire."
When documenting subjective information, it is best practice to use the resident's exact words in quotation marks. This avoids interpretation and provides the most accurate account of the resident's complaint. The other options are interpretations or generalizations of what the resident said.
After a resident refuses their scheduled blood pressure medication, and the charge nurse has been notified, what is the CMT's primary documentation responsibility?
Answer: Document the refusal on the MAR, note the reason for refusal if given, and record that the nurse was notified.
Proper documentation of a medication refusal is critical. The CMT must record that the dose was not taken, the reason for the refusal, and the actions taken (such as notifying the nurse). This creates a clear and legal record of the event and the follow-up.
Which of the following is an unacceptable practice when documenting in a medical record due to the high risk of medication errors?
Answer: Using the abbreviation "U" for "unit" when documenting an insulin dose.
The abbreviation "U" for unit is on The Joint Commission's "Do Not Use" list because it can easily be mistaken for a "0" (zero), the number "4", or "cc", leading to a significant overdose. The other options represent safe documentation practices.
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?
Answer: Chart that the medication was given immediately at 10:00, and then make a follow-up entry documenting the resident's response later.
The administration of the medication should be charted immediately to ensure the record is current. For PRN medications, a follow-up entry is crucial to document the effectiveness and the resident's response after a reasonable time has passed for the medication to work. This completes the documentation cycle.
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?
Answer: The entry must include the date, time, and the CMT's legible signature and professional title.
For a medical record entry to be legally sound, it must be clearly identifiable to the person who made it. This requires the date and time of the entry, as well as the full signature and professional title (e.g., J. Smith, CMT) of the individual. This ensures accountability and authenticity.