CNA Documentation & Record Keeping 3

Question 1

Which statement about electronic health records (EHR) is TRUE?

Accepted Answer

EHRs allow authorized staff to access patient information quickly and securely

Answer

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?

Accepted Answer

Input and output of fluids

Answer

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:

Accepted Answer

Time, location, what the resident was doing, injuries observed, and who was notified

Answer

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?

Accepted Answer

To record routine, repeated observations and care tasks efficiently

Answer

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?

Accepted Answer

Personal opinions about the resident's family

Answer

Medical records must contain factual, professional observations only; personal opinions or judgments about residents or their families are inappropriate and unprofessional.

CNA Practice Test

CNA Practice Test

CNA Documentation & Record Keeping 3