CNA Documentation & Record Keeping 3 — Questions and Answers
Question 1: Which statement about electronic health records (EHR) is TRUE?
- CNAs should share their login credentials with coworkers for efficiency
- EHRs allow authorized staff to access patient information quickly and securely (Correct answer)
- Paper records are always more secure than EHRs
- CNAs are not permitted to document in EHR systems
Correct answer: EHRs allow authorized staff to access patient information quickly and securely
EHRs improve access and care coordination for authorized providers, but each user must maintain their own unique login credentials.
Question 2: A resident's care plan notes 'I&O.' What does this mean the CNA must track?
- Incidents and outcomes
- Input and output of fluids (Correct answer)
- Independence and orientation
- Infections and observations
Correct answer: Input and output of fluids
I&O stands for intake and output, requiring the CNA to measure and record all fluids consumed and all fluid output such as urine.
Question 3: When documenting a resident's fall, the CNA should include:
- Only the time and location of the fall
- Time, location, what the resident was doing, injuries observed, and who was notified (Correct answer)
- A brief note that a fall occurred
- The CNA's opinion about why the fall happened
Correct answer: Time, location, what the resident was doing, injuries observed, and who was notified
Complete incident documentation includes specific details—time, location, circumstances, observed injuries, and notifications—to support follow-up care and legal protection.
Question 4: What is the purpose of a flow sheet in a resident's chart?
- To summarize the resident's entire medical history
- To record routine, repeated observations and care tasks efficiently (Correct answer)
- To document physician orders only
- To track staff scheduling
Correct answer: To record routine, repeated observations and care tasks efficiently
Flow sheets allow CNAs to quickly document repetitive tasks like vital signs, ADLs, and repositioning in a structured, time-efficient format.
Question 5: Which of the following should NEVER be documented in a medical record?
- Exact time care was given
- Resident's response to care
- Personal opinions about the resident's family (Correct answer)
- Changes in the resident's condition
Correct answer: Personal opinions about the resident's family
Medical records must contain factual, professional observations only; personal opinions or judgments about residents or their families are inappropriate and unprofessional.
Question 6: A resident reports pain rated 7 out of 10. How should the CNA document this?
- 'Resident is in extreme pain'
- 'Resident reported pain level of 7/10' (Correct answer)
- 'Resident looks uncomfortable'
- 'Pain noted; nurse aware'
Correct answer: 'Resident reported pain level of 7/10'
Pain should be documented using the resident's own words and the numeric scale rating to provide objective, measurable data.
Question 7: Under HIPAA, a CNA may share a resident's medical information with:
- Anyone who asks politely
- Other care team members directly involved in that resident's care (Correct answer)
- The resident's neighbors if they ask
- A coworker on another unit out of curiosity
Correct answer: Other care team members directly involved in that resident's care
HIPAA permits sharing protected health information only with members of the care team who have a need to know for treatment purposes.
CNA Documentation & Record Keeping 3
Which statement about electronic health records (EHR) is TRUE?