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
A controlled substance count at shift change reveals one tablet is missing. What is the appropriate response?
Answer: Report the discrepancy to the nurse immediately and complete required documentation
Controlled substance discrepancies must be reported immediately and documented per state law and facility policy to initiate an investigation.
What is the correct documentation for a medication that was held per physician order?
Answer: Circle or mark the scheduled time with the 'hold' code and note the order
A hold order must be documented with the appropriate exception code and a reference to the physician order authorizing the hold.
In electronic medication administration records (eMARs), what feature helps prevent wrong-time medication errors?
Answer: Automated alerts that flag medications administered outside the allowed time window
eMARs use time-window alerts to warn staff when a medication is being documented significantly before or after its scheduled time.
Why is it important to document the specific site when applying a transdermal patch?
Answer: To ensure rotation of sites and avoid skin irritation or overdose from stacking patches
Documenting the patch site ensures proper rotation and prevents accidental double application, which could cause toxic drug levels.
A medication technician gives a medication and then realizes they forgot to check the resident's name band first. What should they do?
Answer: Verify identity immediately, report to the nurse, and document the event as an incident
Skipping identity verification is a protocol breach that must be reported and documented even if no immediate harm occurred.
When a resident is discharged, which statement about MAR documentation is correct?
Answer: The MAR becomes part of the permanent medical record and must be retained per facility and state policy
MARs are legal medical records that must be retained for the period specified by state law and facility policy, typically several years.
Which of the following BEST describes the chain of custody for controlled substances?
Answer: A documented record tracking controlled substances from receipt through administration or waste
Chain of custody ensures every controlled substance is accounted for at every step, from delivery to use, to detect diversion.