Documentation and Legal Ethics Flashcards
6 cards from real HCA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Documentation and Legal Ethics flashcards as text
While documenting in a resident's paper chart, a Health Care Assistant realizes they wrote down the wrong time for when a task was completed. What is the correct procedure for fixing this error?
Answer: Draw a single line through the incorrect time, write "error" or "mistaken entry" above it with their initials, and then record the correct time.
A patient's chart is a legal document. Errors must be corrected in a way that maintains the integrity of the record. The standard and legal method is to draw a single line through the error so it is still legible, label it as an error, initial it, and add the correct information. This ensures transparency and accountability.
Which of the following is the best example of objective information a Health Care Assistant should document?
Answer: A red, raised rash is observed on the client's left arm.
Objective data is factual, observable, and measurable information collected through the senses. A red, raised rash is something the HCA can directly see. The other options are examples of subjective data, which are based on personal feelings, opinions, or statements from the client or their family.
A Health Care Assistant notices several unexplained bruises on a resident who is unable to communicate verbally. The resident flinches when the HCA gently touches their arm. What is the HCA's primary legal and ethical responsibility?
Answer: Immediately report their objective observations to their supervising nurse according to facility policy.
Health Care Assistants are mandated reporters, legally required to report any suspicion of abuse or neglect. The most critical and immediate action is to report the objective findings (bruises, flinching) to the supervising nurse. This initiates the formal process of investigation and ensures the resident's safety. Delaying the report or confronting family could put the resident at further risk.
A client's care plan includes a valid Do Not Resuscitate (DNR) order. This legal document specifically instructs the healthcare team to do which of the following?
Answer: Not perform cardiopulmonary resuscitation (CPR) if the client stops breathing or their heart stops.
A Do Not Resuscitate (DNR) order is a specific medical order that means cardiopulmonary resuscitation (CPR) should not be attempted if a person's heart or breathing stops. It does not mean "do not treat"; the client will still receive all other appropriate medical care, including pain management and comfort measures.
Which of the following tasks falls outside the typical scope of practice for a Health Care Assistant?
Answer: Documenting observations about a client's appetite and fluid intake.
Adjusting medication dosages, especially for high-risk drugs like insulin, requires the clinical judgment and licensure of a registered nurse or physician. This task is strictly outside the HCA's scope of practice. The other options are standard duties for a Health Care Assistant.
A resident expresses that they are feeling lonely and sad. Which action by the Health Care Assistant best demonstrates the ethical principle of beneficence?
Answer: Offering to sit and talk with the resident for a few minutes or suggesting a quiet activity they enjoy.
Beneficence is the ethical principle of acting for the good and well-being of others. Taking the time to offer companionship and an activity demonstrates a commitment to promoting the resident's emotional well-being, which is a key aspect of doing good. The other options are dismissive or fail to actively promote the resident's welfare.