General CNA Practice CNA Practice Documentation and Reporting 1

Question 1

When should a CNA document care provided to a resident?

Accepted Answer

After completing the care

Answer

Documentation must occur after care is provided to accurately reflect what was actually done.

Question 2

Which abbreviation is commonly used in medical records to mean 'as needed'?

Accepted Answer

PRN

Answer

PRN (from Latin 'pro re nata') means 'as needed' and indicates care or medication given only when a specific condition arises.

Question 3

What is the FIRST action a CNA should take when noticing a change in a resident's condition?

Accepted Answer

Report the change to the nurse immediately

Answer

A change in condition must be reported to the nurse immediately so appropriate assessment and intervention can occur without delay.

Question 4

Which of the following is the correct way to correct a documentation error in a paper medical record?

Accepted Answer

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

Answer

A single line through the error preserves the original entry for legal purposes while clearly marking it as incorrect.

Question 5

What is the primary purpose of an incident report?

Accepted Answer

To document unexpected events in order to improve safety and prevent recurrence

Answer

Incident reports document unexpected events to identify patterns, improve facility safety, and prevent future occurrences.

General Practice Test