Documentation & Record Keeping Flashcards

When a CNA makes an error while charting, what is the correct way to correct it?

Answer: Draw a single line through the error, write 'error,' initial, and date it

Errors in paper charting must be corrected by drawing one line through the mistake, labeling it 'error,' and adding initials and date so the original entry remains legible.

Which of the following is an example of objective documentation?

Answer: 'Patient's blood pressure is 120/80 mmHg'

Objective data consists of measurable, observable facts such as vital sign readings, while words like 'appears' or 'seems' reflect subjective interpretation.

A resident's medical record is legally considered:

Answer: A legal document that can be used in court

Medical records are legal documents that can be subpoenaed and used as evidence in legal proceedings, making accurate documentation critical.

Which abbreviation correctly represents 'twice a day' in medical documentation?

Answer: BID

BID (bis in die) means twice a day; QD means once daily, TID means three times a day, and PRN means as needed.

A CNA notices a resident refused breakfast but does not document it. This is an example of:

Answer: Negligence, because a failure to document can equal a failure to provide care

In healthcare, 'if it wasn't documented, it wasn't done'—omitting significant observations like meal refusal can be considered negligence.

What does the abbreviation 'NPO' mean in a resident's care plan?

Answer: Nothing by mouth

NPO stands for 'nil per os,' a Latin phrase meaning nothing by mouth, indicating the patient should not eat or drink.

How soon after providing care should a CNA document the service?

Answer: As soon as possible after care is given

Documentation should occur as soon as possible after care is provided to ensure accuracy and prevent details from being forgotten.