Documentation & Record Keeping Flashcards

Which statement about electronic health records (EHR) is TRUE?

Answer: EHRs allow authorized staff to access patient information quickly and securely

EHRs improve access and care coordination for authorized providers, but each user must maintain their own unique login credentials.

A resident's care plan notes 'I&O.' What does this mean the CNA must track?

Answer: Input and output of fluids

I&O stands for intake and output, requiring the CNA to measure and record all fluids consumed and all fluid output such as urine.

When documenting a resident's fall, the CNA should include:

Answer: Time, location, what the resident was doing, injuries observed, and who was notified

Complete incident documentation includes specific details—time, location, circumstances, observed injuries, and notifications—to support follow-up care and legal protection.

What is the purpose of a flow sheet in a resident's chart?

Answer: To record routine, repeated observations and care tasks efficiently

Flow sheets allow CNAs to quickly document repetitive tasks like vital signs, ADLs, and repositioning in a structured, time-efficient format.

Which of the following should NEVER be documented in a medical record?

Answer: Personal opinions about the resident's family

Medical records must contain factual, professional observations only; personal opinions or judgments about residents or their families are inappropriate and unprofessional.

A resident reports pain rated 7 out of 10. How should the CNA document this?

Answer: 'Resident reported pain level of 7/10'

Pain should be documented using the resident's own words and the numeric scale rating to provide objective, measurable data.

Under HIPAA, a CNA may share a resident's medical information with:

Answer: Other care team members directly involved in that resident's care

HIPAA permits sharing protected health information only with members of the care team who have a need to know for treatment purposes.