Documentation & Record Keeping 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 & Record Keeping flashcards as text
An incident report is filed after a resident falls. Who is responsible for completing it?
Answer: The staff member who witnessed or discovered the incident
The staff member who directly observed or found the incident is responsible for completing the incident report promptly and accurately.
A CNA notices a resident's urine is dark brown. How should this be documented?
Answer: 'Resident urinated; color dark brown, reported to charge nurse at 1400'
Specific, objective language describing color with exact time and notification ensures the clinical team has accurate information to act on.
Which of the following best describes the minimum data set (MDS)?
Answer: A standardized assessment tool used in long-term care to evaluate residents' health status
The MDS is a federally mandated, standardized assessment completed periodically to evaluate resident health, function, and care needs in long-term care facilities.
What does the medical abbreviation 'SOB' mean in documentation?
Answer: Shortness of breath
SOB stands for shortness of breath, a critical symptom that must be documented and reported to the nurse immediately.
A resident asks to see their own medical records. Under HIPAA, the CNA should:
Answer: Explain that residents have the right to their records and direct them to the nurse or appropriate staff
HIPAA grants residents the right to access their medical records; the CNA should acknowledge this right and direct the request to the appropriate staff member.
When documenting a skin wound on a resident, the CNA should include:
Answer: Location, size, color, drainage, surrounding skin condition, and time of observation
Wound documentation requires detailed, objective description of all observable characteristics to track changes and communicate status to the care team.
Which practice violates medical record confidentiality?
Answer: Discussing a resident's condition in a public hallway where others can hear
Discussing confidential resident information in areas where unauthorized individuals can overhear is a HIPAA violation that breaches the resident's right to privacy.