Documentation and Record Keeping Flashcards

What is the primary reason that documentation must be completed in ink rather than pencil?

Answer: Pencil can be erased, making medical records alterable and unreliable

Ink creates a permanent record that cannot be erased, protecting the integrity of the legal document.

A nurse aide observes redness on a resident's coccyx. Which action should be taken first?

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

Skin breakdown is a reportable change in condition that requires immediate documentation and nursing assessment.

Which of the following is NOT an appropriate component of nursing documentation?

Answer: The nurse aide's personal opinion of the resident's personality

Personal opinions about a resident are not appropriate in medical documentation, which must remain factual and professional.

Under HIPAA, who has the right to access a resident's medical record?

Answer: Only the resident and those directly involved in their care or authorized by the resident

HIPAA protects the privacy of medical records, limiting access to the resident and authorized individuals involved in care.

A nurse aide leaves a resident's chart open at the nurse's station where visitors can read it. This violates:

Answer: HIPAA privacy regulations

Leaving medical records visible to unauthorized individuals constitutes a HIPAA privacy breach.

When documenting vital signs, what should the nurse aide do if a value falls outside the normal range?

Answer: Record the value and notify the charge nurse immediately

Abnormal vital signs must be documented accurately and reported promptly so the charge nurse can intervene.

What does the term 'care plan' describe in long-term care documentation?

Answer: A written document outlining individualized goals and approaches for a resident's care

The care plan is an individualized written guide that directs the entire care team in meeting a resident's specific needs and goals.