Documentation & Record Keeping Flashcards

A CNA documents care that was not actually performed. This constitutes:

Answer: Fraud and falsification of records

Charting care that was never performed is fraudulent, unethical, and can result in termination, loss of certification, and legal consequences.

The term 'subjective data' in documentation refers to:

Answer: Information the resident tells you about how they feel

Subjective data is what the resident reports or describes about their own symptoms or feelings, which cannot be independently measured or verified.

What should a CNA do if they forget to document care immediately after providing it?

Answer: Write a late entry noting the actual time of care and the time of documentation

A late entry is permissible and should clearly indicate both the actual time care was given and the current time of documentation.

Which vital sign documentation is written correctly?

Answer: 'BP 138/88 mmHg at 0900'

Vital signs must be documented with exact numeric values, units, and the time taken to provide meaningful clinical data.

A resident's chart contains information about a positive HIV status. A CNA shares this with a coworker who is not involved in the resident's care. This violates:

Answer: HIPAA privacy regulations

Sharing any protected health information with unauthorized individuals, regardless of workplace setting, is a direct HIPAA violation.

Why is it important to document the time when care was given?

Answer: It creates a chronological record that helps track the resident's condition over time

Time-stamped entries create an accurate timeline of care and observations, which is essential for coordinating treatment and legal documentation.

When a resident is transferred to a hospital, which document typically accompanies them?

Answer: A transfer summary or copy of relevant medical records

A transfer summary provides the receiving facility with key clinical information to ensure continuity of care and patient safety.