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
Which of the following observations should a CNA report to the nurse IMMEDIATELY?
Answer: A resident is having difficulty breathing
Difficulty breathing is a potentially life-threatening condition that requires immediate nursing assessment and intervention.
What does 'ADL' stand for in CNA documentation?
Answer: Activities of Daily Living
ADL stands for Activities of Daily Living, which includes tasks such as bathing, dressing, eating, grooming, and toileting.
When documenting a resident's intake and output (I&O), what is included in 'output'?
Answer: Urine, stool, vomit, and wound drainage
Output includes all fluids leaving the body, such as urine, stool, emesis (vomiting), wound drainage, and any other measurable losses.
Which statement about verbal reports in healthcare is TRUE?
Answer: Verbal reports must always be followed up with written documentation
While verbal communication is important for immediate notification, it must always be followed by written documentation to create a complete legal record.
A resident tells the CNA, 'I feel very dizzy.' What type of data is this?
Answer: Subjective data
Information reported by the resident about their own personal experience is subjective data, as it cannot be directly measured by the CNA.
What should a CNA do if asked to sign documentation for care they did not personally provide?
Answer: Refuse to sign and report the request to the supervisor
Signing for care you did not provide is fraudulent and illegal; it must be refused and the request reported to protect residents and staff.
Which of the following best describes following the 'chain of command' when reporting a concern?
Answer: Reporting to your immediate supervisor first before escalating to higher authority
Following the chain of command means reporting concerns to your immediate supervisor first, then escalating if the issue is not appropriately addressed.