Documentation and Reporting Flashcards
7 cards from real CNA 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
When using an electronic health record (EHR) system, a CNA should:
Answer: Log out after each session to protect resident privacy
Always logging out protects resident confidentiality and ensures each entry is attributed to the correct caregiver, which is required by HIPAA.
Which of the following is generally NOT an acceptable abbreviation in medical documentation?
Answer: U (units)
The abbreviation 'U' for units is on the Joint Commission's 'Do Not Use' list because it can be misread as '0' (zero), potentially causing a ten-fold medication error.
A resident refuses to take their scheduled medication. The CNA should:
Answer: Document the refusal and notify the charge nurse
Medication refusal must be documented as refused and reported to the charge nurse so the licensed nurse can follow up appropriately.
The phrase 'If it wasn't documented, it wasn't done' means:
Answer: Undocumented care is legally considered as not having occurred
In healthcare and law, care that is not documented cannot be proven to have occurred, making thorough documentation essential for legal protection and continuity of care.
A resident with dementia accuses the CNA of stealing her jewelry. The CNA should:
Answer: Report the accusation to the charge nurse and document the incident
All accusations, regardless of the resident's cognitive status, must be reported to the charge nurse and documented to protect both the resident and the CNA.
What is the primary purpose of the Minimum Data Set (MDS) in long-term care documentation?
Answer: To standardize assessment data for care planning and Medicare/Medicaid reimbursement
The MDS is a federally mandated standardized assessment tool used in nursing facilities to guide care planning and determine Medicare/Medicaid payment levels.
When documenting a wound, which of the following is an OBJECTIVE observation?
Answer: The wound measures 3 cm x 2 cm with yellow drainage
Objective wound documentation includes measurable data such as size in centimeters and observable characteristics like drainage color, rather than subjective interpretations.