HAC Documentation & Reporting Flashcards

Which of the following is the MOST important reason for accurate documentation in patient care?

Answer: To ensure continuity of care and legal accountability

Accurate documentation creates a legal record of care and ensures that all members of the healthcare team have the information needed to provide consistent, safe care.

When a healthcare aide makes an error in a paper chart, the correct procedure is to:

Answer: Draw a single line through the error, write 'error', initial it, and add the correct information

A single line through the error with 'error,' the aide's initials, and the correct entry preserves the original content and documents who made the correction, maintaining chart integrity.

Which change in a patient's condition should a healthcare aide report to the nurse immediately?

Answer: Patient's urine output appears dark brown and has decreased significantly

Dark, decreased urine output can indicate dehydration, kidney dysfunction, or other serious conditions requiring prompt clinical assessment.

The abbreviation 'PRN' used in a care plan means:

Answer: As needed

PRN (from Latin 'pro re nata') means 'as needed,' indicating that an intervention should only be performed when a specific condition or need arises.

When documenting the intake and output (I&O) of a patient, which of the following counts as OUTPUT?

Answer: Urine, wound drainage, and emesis

Output includes all fluids leaving the body: urine, vomit, wound drainage, and other measurable fluid losses.

A healthcare aide notices a patient has a new skin tear on their forearm during morning care. What should the aide do first?

Answer: Report the finding to the nurse immediately and document it objectively

New skin injuries must be reported to the nurse promptly and documented objectively so they can be assessed, treated, and recorded as a baseline finding.