Health Care Assistant Documentation and Legal Ethics 1 Flashcards

A resident verbally refuses their scheduled medication. What is the HCA's primary documentation responsibility?

Answer: Document the refusal, the reason given by the resident, and the nurse or supervisor who was notified

Refusals of care or treatment must be documented completely, including what was refused, the resident's stated reason, and notification of the appropriate supervising nurse. This protects both the resident's rights and the HCA legally.

Which of the following best describes 'negligence' in the context of an HCA's legal responsibilities?

Answer: Failing to provide the standard of care that a reasonably competent HCA would provide, resulting in harm

Negligence occurs when a care provider fails to meet the accepted standard of care, and that failure causes harm to the patient or resident. It does not require intent to harm.

An HCA notices that a progress note from the previous shift contains inaccurate information about a resident's condition. What is the most appropriate action?

Answer: Report the discrepancy to the supervising nurse and follow facility policy for addendum or correction

HCAs should never alter another staff member's documentation. The correct approach is to notify the supervising nurse and follow facility-specific policy, which typically involves an addendum rather than altering the original entry.

A resident's adult child calls and requests an update on their parent's health status. The resident has not provided written consent for information to be released to family members. What should the HCA do?

Answer: Politely decline to share health information and direct the caller to the appropriate supervisor or nurse

Privacy legislation requires that personal health information only be shared with those the resident has authorized. Without documented consent, an HCA must not disclose health details, regardless of the caller's relationship to the resident.

When documenting care provided, an HCA should always use which of the following approaches?

Answer: Use approved abbreviations, factual language, and sign with their full name and designation

Legal care records must use only facility-approved abbreviations, objective and factual language, and must be signed by the documenting staff member with their name and role. This ensures records are accurate, professional, and legally defensible.

An HCA witnesses a colleague behaving in a way that they believe constitutes abuse of a resident. Under mandatory reporting obligations, what must the HCA do?

Answer: Report the observed behaviour immediately to the supervisor and follow the facility's abuse reporting protocol

HCAs are mandatory reporters and are legally required to report suspected or witnessed abuse immediately to a supervisor and through the facility's established reporting protocol. Delaying or handling it informally does not meet the legal obligation.