CNA Documentation & Record Keeping 2

Question 1

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

Accepted Answer

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

Answer

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?

Accepted Answer

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

Answer

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:

Accepted Answer

A legal document that can be used in court

Answer

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?

Accepted Answer

BID

Answer

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:

Accepted Answer

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

Answer

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

CNA Practice Test

CNA Practice Test

CNA Documentation & Record Keeping 2