Documentation and Reporting Flashcards

A resident refuses their scheduled medication. What must the medication technician document?

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.

Which abbreviation is on the Joint Commission's 'Do Not Use' list due to misinterpretation risk?

Answer: U (for units)

'U' for units is prohibited because it can be misread as '0' or '4,' leading to dangerous dosing errors.

After giving a PRN medication, what additional documentation is required compared to a routine medication?

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.

A medication technician notices a discrepancy between the MAR and the medication bottle label. What is the correct action?

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.

What does the term 'late entry' mean in medical documentation?

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.

Which of the following is the correct way to correct a handwritten error on a paper MAR?

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.

A medication technician administered a medication to the wrong resident. After ensuring the resident's safety, what is the FIRST documentation step?

Answer: Complete an incident or occurrence report

An incident/occurrence report must be completed promptly to initiate facility follow-up and protect resident safety.