CNA Documentation and Reporting 3 — Questions and Answers
Question 1: How should a CNA correct an error made in a handwritten medical record?
- Use correction fluid (white-out) to cover the mistake
- Erase the error completely
- Draw a single line through the error, write 'error,' initial, and date (Correct answer)
- Tear out the page and rewrite the entry
Correct answer: Draw a single line through the error, write 'error,' initial, and date
A single line through the error preserving legibility, followed by 'error,' initials, and date is the legally accepted method for correcting medical record mistakes.
Question 2: When a CNA witnesses a resident fall, what additional documentation must be completed beyond routine charting?
- A transfer summary
- An incident/occurrence report (Correct answer)
- A discharge form
- A diet change request
Correct answer: An incident/occurrence report
An incident report must be completed for any unexpected event like a fall to document the circumstances, injuries, and response for quality improvement and legal purposes.
Question 3: Under HIPAA, which of the following parties may receive protected health information WITHOUT the resident's written consent?
- The resident's neighbor who is also a nurse
- The resident's employer
- A physician involved in the resident's treatment (Correct answer)
- A local news reporter
Correct answer: A physician involved in the resident's treatment
HIPAA's Treatment, Payment, and Operations (TPO) provisions allow sharing information with healthcare providers directly involved in a patient's care without separate consent.
Question 4: Which abbreviation correctly means 'nothing by mouth'?
- PRN
- NPO (Correct answer)
- BID
- SOB
Correct answer: NPO
NPO stands for 'nil per os,' a Latin phrase meaning nothing by mouth, used when a resident must not eat or drink.
Question 5: A CNA discovers a coworker has been documenting care that was never provided. What should the CNA do?
- Ignore it to avoid conflict
- Report the falsification to the charge nurse or supervisor (Correct answer)
- Fix the records to reflect what actually happened
- Confront the coworker publicly at the nurses' station
Correct answer: Report the falsification to the charge nurse or supervisor
Falsifying medical records is illegal and endangers residents; the CNA is ethically and professionally obligated to report it to a supervisor.
Question 6: Medical records are considered legal documents primarily because they:
- Are printed on official paper
- Are signed by the facility administrator
- Can be used as evidence in legal proceedings (Correct answer)
- Are stored in a locked cabinet
Correct answer: Can be used as evidence in legal proceedings
Medical records serve as legal evidence of the care provided and can be subpoenaed for court proceedings, making accuracy and honesty critical.
Question 7: Which information must ALWAYS be included when a CNA documents an entry in the medical record?
- The CNA's home address
- Date, time, and signature/initials of the CNA (Correct answer)
- The family member's contact information
- The cost of care provided
Correct answer: Date, time, and signature/initials of the CNA
Every documentation entry must include the date, time, and the caregiver's identifying signature or initials to ensure accountability and a clear timeline.
CNA Documentation and Reporting 3
How should a CNA correct an error made in a handwritten medical record?