Documentation and Reporting Flashcards

A medication technician notices a nurse has already documented a medication on the eMAR before the technician gave it. What should the technician do?

Answer: Alert the nurse immediately to clarify who gave the medication and correct the record

Duplicate documentation must be resolved immediately to prevent double-dosing and to ensure the record accurately reflects who administered the medication.

What does HIPAA require medication technicians to do when discussing a resident's medication regimen?

Answer: Discuss only with authorized care team members in private settings

HIPAA mandates that protected health information, including medication details, be shared only with authorized individuals in appropriate settings.

A care plan notes that a resident has a new swallowing difficulty. How does this affect documentation?

Answer: The technician must document that the medication was given with the modified method and resident tolerated it

When a care plan modification exists, the medication technician must document adherence to the modified protocol and the resident's response.

Which of the following is the MOST accurate description of an incident report's purpose?

Answer: To identify errors and near-misses so the facility can improve safety systems

Incident reports are quality improvement tools designed to analyze events and prevent recurrence, not to punish individuals.

When wasting a partial dose of a controlled substance, what documentation is required?

Answer: The amount wasted, the witness's signature, and the administering technician's signature

Controlled substance waste must be witnessed and co-signed to verify the disposal and prevent diversion.

A resident receives oxygen therapy in addition to medications. Which of the following is within the documentation scope of a medication technician?

Answer: Medications administered, including the oxygen flow rate if it is ordered as a medication

When oxygen is ordered as a medication with a specific flow rate, the medication technician documents it on the MAR like any other medication.

If a resident experiences a fall during the medication pass, what is the correct documentation sequence?

Answer: Ensure resident safety, notify the nurse, complete an incident report, and document observations in the record

Resident safety is the first priority, followed by immediate nurse notification and concurrent incident reporting regardless of injury status.