CMT - Certified Medical Technician Medical Records and Charting Questions and Answers 1 — Questions and Answers
Question 1: A CMT makes an error while documenting in a resident's paper chart. What is the legally acceptable method for correcting this mistake?
- Use correction fluid to cover the error completely and write the correct information over it.
- Draw a single line through the error, write "error" above it, and add the CMT's initials and the date. (Correct answer)
- Scribble over the incorrect entry until it is unreadable and write the correct information nearby.
- Leave the error as is and add a correct entry on the next available line in the chart.
Correct answer: Draw a single line through the error, write "error" above it, and add the CMT's initials and the date.
The correct and legal procedure for correcting an error in a paper medical record is to draw a single line through the incorrect entry so that it remains legible, then write "error" or "mistaken entry" nearby, and add the date, time, and initials of the person making the correction. This maintains the integrity of the legal document.
Question 2: A resident tells the CMT, "My stomach feels like it's on fire." Which of the following is the most appropriate and accurate way to document this statement in the medical record?
- Resident has severe heartburn.
- Resident states, "My stomach feels like it's on fire." (Correct answer)
- Resident is complaining of gastrointestinal distress.
- Resident appears to be in significant pain from their stomach.
Correct answer: Resident states, "My stomach feels like it's on fire."
When documenting subjective information, it is best practice to use the resident's exact words in quotation marks. This avoids interpretation and provides the most accurate account of the resident's complaint. The other options are interpretations or generalizations of what the resident said.
Question 3: After a resident refuses their scheduled blood pressure medication, and the charge nurse has been notified, what is the CMT's primary documentation responsibility?
- Leave the medication administration record (MAR) blank for that time slot.
- Persuade the resident to take the medication and then chart it as given.
- Document the refusal on the MAR, note the reason for refusal if given, and record that the nurse was notified. (Correct answer)
- Chart the medication as 'held' without providing any additional context or reason.
Correct answer: Document the refusal on the MAR, note the reason for refusal if given, and record that the nurse was notified.
Proper documentation of a medication refusal is critical. The CMT must record that the dose was not taken, the reason for the refusal, and the actions taken (such as notifying the nurse). This creates a clear and legal record of the event and the follow-up.
Question 4: Which of the following is an unacceptable practice when documenting in a medical record due to the high risk of medication errors?
- Using the abbreviation "U" for "unit" when documenting an insulin dose. (Correct answer)
- Writing out "international unit" instead of using an abbreviation.
- Documenting "0.5 mg" instead of ".5 mg".
- Using military time (e.g., 14:00) for entries.
Correct answer: Using the abbreviation "U" for "unit" when documenting an insulin dose.
The abbreviation "U" for unit is on The Joint Commission's "Do Not Use" list because it can easily be mistaken for a "0" (zero), the number "4", or "cc", leading to a significant overdose. The other options represent safe documentation practices.
Question 5: A CMT administers a PRN (as needed) pain medication to a resident at 10:00. According to best practices, what is the correct procedure for documenting this event?
- Document both the administration and the resident's response to it at the end of the shift.
- Chart that the medication was given immediately at 10:00, and then make a follow-up entry documenting the resident's response later. (Correct answer)
- Wait until the resident states they have relief before documenting the administration.
- Document the administration at 10:00 and assume the medication was effective unless the resident complains again.
Correct answer: Chart that the medication was given immediately at 10:00, and then make a follow-up entry documenting the resident's response later.
The administration of the medication should be charted immediately to ensure the record is current. For PRN medications, a follow-up entry is crucial to document the effectiveness and the resident's response after a reasonable time has passed for the medication to work. This completes the documentation cycle.
Question 6: When completing a charting entry in a resident's medical record, which of the following is essential for the entry to be considered legally valid?
- The entry must be co-signed by the supervising nurse.
- The entry must include the date, time, and the CMT's legible signature and professional title. (Correct answer)
- The entry must be written in blue ink only.
- The entry must be reviewed by the facility administrator within 24 hours.
Correct answer: The entry must include the date, time, and the CMT's legible signature and professional title.
For a medical record entry to be legally sound, it must be clearly identifiable to the person who made it. This requires the date and time of the entry, as well as the full signature and professional title (e.g., J. Smith, CMT) of the individual. This ensures accountability and authenticity.
CMT - Certified Medical Technician Medical Records and Charting Questions and Answers 1
A CMT makes an error while documenting in a resident's paper chart.
What is the legally acceptable method for correcting this mistake?