CNA Documentation & Record Keeping 2 — Questions and Answers
Question 1: When a CNA makes an error while charting, what is the correct way to correct it?
- Use correction fluid to cover the mistake
- Draw a single line through the error, write 'error,' initial, and date it (Correct answer)
- Erase the error completely and rewrite
- Remove the page and start a new one
Correct 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.
Question 2: Which of the following is an example of objective documentation?
- 'Patient appears anxious'
- 'Patient's blood pressure is 120/80 mmHg' (Correct answer)
- 'Patient seems to be in pain'
- 'Patient looks dehydrated'
Correct 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.
Question 3: A resident's medical record is legally considered:
- The personal property of the CNA who documented it
- The property of the resident only
- A legal document that can be used in court (Correct answer)
- Confidential but not legally binding
Correct 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.
Question 4: Which abbreviation correctly represents 'twice a day' in medical documentation?
- QD
- BID (Correct answer)
- TID
- PRN
Correct 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.
Question 5: A CNA notices a resident refused breakfast but does not document it. This is an example of:
- Acceptable practice if the nurse is told verbally
- Negligence, because a failure to document can equal a failure to provide care (Correct answer)
- Normal since CNAs don't chart meals
- A minor oversight with no consequences
Correct 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.
Question 6: What does the abbreviation 'NPO' mean in a resident's care plan?
- Nothing by mouth (Correct answer)
- No physical orders
- Neurological pulse observation
- Night precautions only
Correct 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.
Question 7: How soon after providing care should a CNA document the service?
- At the end of the shift to save time
- As soon as possible after care is given (Correct answer)
- Within 24 hours
- Only when the charge nurse requests it
Correct 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.
CNA Documentation & Record Keeping 2
When a CNA makes an error while charting, what is the correct way to correct it?