CMT Documentation and Reporting 2

Question 1

A resident refuses their scheduled medication. What must the medication technician document?

Accepted Answer

The refusal, reason given, and nurse notified

Answer

Refusals must be documented with the reason stated by the resident and notification to the supervising nurse.

Question 2

Which abbreviation is on the Joint Commission's 'Do Not Use' list due to misinterpretation risk?

Accepted Answer

U (for units)

Answer

'U' for units is prohibited because it can be misread as '0' or '4,' leading to dangerous dosing errors.

Question 3

After giving a PRN medication, what additional documentation is required compared to a routine medication?

Accepted Answer

The resident's response or effectiveness must be recorded

Answer

PRN medications require follow-up documentation of the resident's response to assess whether the medication was effective.

Question 4

A medication technician notices a discrepancy between the MAR and the medication bottle label. What is the correct action?

Accepted Answer

Withhold the medication and report to the nurse immediately

Answer

Any discrepancy between the MAR and medication label must be reported to the nurse before administration to prevent errors.

Question 5

What does the term 'late entry' mean in medical documentation?

Accepted Answer

A note added after the fact to record information that was omitted at the time of care

Answer

A late entry is a properly labeled addendum added to the record when documentation was accidentally omitted during the care event.

(CMT) Certified Medication Technician Practice Test