CNA Documentation and Reporting 3

Question 1

How should a CNA correct an error made in a handwritten medical record?

Accepted Answer

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

Answer

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?

Accepted Answer

An incident/occurrence report

Answer

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?

Accepted Answer

A physician involved in the resident's treatment

Answer

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'?

Accepted Answer

NPO

Answer

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?

Accepted Answer

Report the falsification to the charge nurse or supervisor

Answer

Falsifying medical records is illegal and endangers residents; the CNA is ethically and professionally obligated to report it to a supervisor.

CNA Practice Test

CNA Practice Test

CNA Documentation and Reporting 3