CNA Practice Documentation and Reporting Flashcards
7 cards from real General practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 CNA Practice Documentation and Reporting flashcards as text
When should a CNA document care provided to a resident?
Answer: After completing the care
Documentation must occur after care is provided to accurately reflect what was actually done.
Which abbreviation is commonly used in medical records to mean 'as needed'?
Answer: PRN
PRN (from Latin 'pro re nata') means 'as needed' and indicates care or medication given only when a specific condition arises.
What is the FIRST action a CNA should take when noticing a change in a resident's condition?
Answer: Report the change to the nurse immediately
A change in condition must be reported to the nurse immediately so appropriate assessment and intervention can occur without delay.
Which of the following is the correct way to correct a documentation error in a paper medical record?
Answer: Draw a single line through the error, write 'error,' initial, and date it
A single line through the error preserves the original entry for legal purposes while clearly marking it as incorrect.
What is the primary purpose of an incident report?
Answer: To document unexpected events in order to improve safety and prevent recurrence
Incident reports document unexpected events to identify patterns, improve facility safety, and prevent future occurrences.
Which of the following is an example of objective data when documenting a resident's condition?
Answer: Temperature reading of 101.2°F
Objective data is measurable and observable with a tool or instrument, such as a specific temperature reading, rather than a subjective interpretation.
A resident refuses to have their blood pressure taken. How should the CNA document this?
Answer: Record that the resident refused the procedure and the time it occurred
Refusals must be accurately documented so the care team is informed and legal accountability is maintained.