Documentation and Record Keeping Flashcards

In electronic health records (EHR), what is the purpose of a unique login for each staff member?

Answer: To ensure accountability and maintain a clear audit trail

Unique logins create an audit trail linking documentation entries to the specific individual who made them.

A nurse aide is documenting a resident's weight. The scale reads 148 lbs, but the aide documents 184 lbs by mistake. This is an example of:

Answer: A transcription error requiring correction per facility policy

Transposing numbers is a common documentation error that must be corrected using proper procedure (single line, 'error,' initials).

Which abbreviation correctly documents that a resident had a bowel movement?

Answer: BM

BM stands for bowel movement and is a standard, approved medical abbreviation used in care documentation.

A resident tells the nurse aide, 'I haven't had a bowel movement in four days.' How should the aide respond first?

Answer: Document the complaint and report it to the charge nurse immediately

Reporting and documenting changes in elimination patterns allows the charge nurse to assess and intervene appropriately.

When using approved abbreviations in documentation, which resource should the nurse aide consult?

Answer: The facility's approved abbreviation list

Each facility maintains its own approved abbreviation list to prevent misinterpretation of documentation.

What does the term 'flow sheet' refer to in long-term care documentation?

Answer: A preprinted form used to record routine care such as vital signs and ADLs

Flow sheets allow staff to quickly document repetitive, routine care activities in a standardized format.

How should a nurse aide document a resident's refusal of a bath?

Answer: 'Resident refused bath; stated she did not want one today; charge nurse notified.'

Documenting a refusal includes the specific care declined, the resident's stated reason, and notification of the charge nurse.