Documentation and Reporting 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 and Reporting flashcards as text
A resident suddenly becomes confused and disoriented. What is the CNA's priority action?
Answer: Report the change immediately to the charge nurse
Sudden changes in mental status must be reported to the charge nurse immediately as they can signal a serious medical condition.
Which communication tool uses the format Situation, Background, Assessment, Recommendation when reporting to a nurse?
Answer: SBAR
SBAR (Situation, Background, Assessment, Recommendation) is a structured communication tool used in healthcare to relay important patient information.
Which observation requires the MOST immediate report to the charge nurse?
Answer: A resident's lips are turning blue
Cyanosis (blue-colored lips) indicates possible oxygen deprivation and is an emergency requiring immediate reporting.
A resident tells the CNA they are experiencing chest pain. What should the CNA do FIRST?
Answer: Notify the charge nurse immediately and stay with the resident
Chest pain is a potential cardiac emergency; the CNA must notify the nurse immediately and remain with the resident.
Which of the following is an example of OBJECTIVE data a CNA should document?
Answer: The resident's oral temperature was 101.2°F
Objective data is measurable and observable; a numeric temperature reading is objective, while words like 'seemed' or 'appeared' are subjective interpretations.
A family member asks to read their adult parent's medical chart. The CNA should:
Answer: Tell them to speak with the charge nurse
Medical record access decisions are made by licensed staff and administration in accordance with HIPAA; the CNA should redirect the family to the charge nurse.
When is the BEST time for a CNA to document care that was provided?
Answer: As soon as possible after providing the care
Documentation should occur as soon as possible after care is given to ensure accuracy and completeness of the medical record.