CNA Practice Documentation and Reporting Flashcards
7 cards from real General practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 CNA Practice Documentation and Reporting flashcards as text
What does the term 'subjective data' mean in nursing documentation?
Answer: Information reported by the resident about how they feel
Subjective data is what the resident tells you about their own experience, such as reporting pain, nausea, or dizziness.
What does 'NPO' mean in medical documentation?
Answer: Nothing by mouth
NPO (from Latin 'nil per os') means nothing by mouth, indicating the resident must not eat or drink anything.
A resident's skin shows new redness over their coccyx. What should the CNA do FIRST?
Answer: Report the finding to the nurse immediately
New skin changes should be reported to the nurse immediately so assessment and interventions can begin before the condition worsens.
Which of the following is true about confidentiality in documentation?
Answer: Medical records should only be shared with those directly involved in the resident's care
HIPAA requires that medical information be shared only with those who have a legitimate need to know for care purposes.
What is a care plan in the nursing home setting?
Answer: A written document outlining individualized goals and interventions for a specific resident
A care plan is an individualized document that outlines specific goals, identified needs, and planned interventions tailored to each resident.
During a shift change report, what is the most important information to communicate to the incoming staff?
Answer: Any changes in the resident's condition that occurred during the shift
Changes in condition are critical to communicate during handoff so incoming staff can prioritize monitoring and care accordingly.
When must vital signs be documented after they are obtained?
Answer: Immediately after they are taken
Vital signs should be documented immediately after measurement to ensure accuracy and timely availability of the information to the care team.