Documentation and Reporting Flashcards
7 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 7 Documentation and Reporting flashcards as text
What is the primary legal purpose of the Medication Administration Record (MAR)?
Answer: To provide a legal record proving what medications were given, when, and by whom
The MAR is a legal document that verifies medication administration and can be used in legal or regulatory proceedings.
A supervising nurse asks the medication technician to sign the MAR for a medication the nurse administered. What should the technician do?
Answer: Refuse, because signing for something you did not do is falsification
Signing for a medication you did not administer is considered falsification of a medical record, which is illegal and grounds for termination.
When must a medication technician document medication administration on the MAR?
Answer: Immediately after giving the medication, before moving to the next resident
Documentation should occur immediately after administration to prevent errors such as double-dosing or missed doses.
Which of the following changes in a resident's condition MUST be reported and documented by a medication technician?
Answer: New rash appearing shortly after medication administration
A new rash after medication administration is a potential adverse reaction that must be reported to the nurse and documented immediately.
What information is NOT typically required on a medication administration entry in the MAR?
Answer: The medication technician's personal home address
Personal home addresses are never part of clinical documentation; only professional identifiers like initials or staff ID are used.
A resident's family member asks to see the MAR to check what medications were given today. What should the medication technician do?
Answer: Explain that medical records requests must go through the appropriate facility process
Medical records, including MARs, must be released through proper HIPAA-compliant processes, not informally handed over.
Which section of the MAR typically records the reason a scheduled medication was NOT administered?
Answer: The exception or reason codes section, often referenced with a circled entry or code
MARs use exception codes (e.g., R for refused, H for hold) in a dedicated area to explain unadministered doses without erasing the scheduled entry.