INACE Documentation and Record Keeping 2 — Questions and Answers
Question 1: When a nurse aide makes an error in a written medical record, what is the correct procedure?
- Use correction fluid to cover the mistake
- Draw a single line through the error, write 'error,' initial it, and enter the correct information (Correct answer)
- Erase the error completely and rewrite
- Tear out the page and start a new one
Correct answer: Draw a single line through the error, write 'error,' initial it, and enter the correct information
A single line through the error preserves the original entry and maintains the integrity of the legal record.
Question 2: Which of the following is an example of objective documentation?
- 'The resident appears to be in pain.'
- 'The resident seems anxious about his procedure.'
- 'The resident's blood pressure is 140/90 mmHg.' (Correct answer)
- 'The resident looks like she did not sleep well.'
Correct answer: 'The resident's blood pressure is 140/90 mmHg.'
Objective documentation records measurable, observable facts rather than assumptions or interpretations.
Question 3: A nurse aide notices a resident refused breakfast. How should this be documented?
- 'Resident was not hungry.'
- 'Resident refused breakfast tray at 0800.' (Correct answer)
- 'Resident did not feel like eating.'
- 'Breakfast was offered but resident was uncooperative.'
Correct answer: 'Resident refused breakfast tray at 0800.'
Documentation should record exactly what happened using factual, non-judgmental language.
Question 4: What does the abbreviation 'NPO' mean in medical documentation?
- Normal physical output
- Nothing by mouth (Correct answer)
- No patient order
- Nighttime patient observation
Correct answer: Nothing by mouth
NPO stands for 'nil per os,' a Latin phrase meaning nothing by mouth, indicating the patient should not eat or drink.
Question 5: How soon after care is provided should a nurse aide document the care?
- At the end of the shift
- Within 24 hours
- As soon as possible after providing the care (Correct answer)
- The next morning during report
Correct answer: As soon as possible after providing the care
Timely documentation ensures accuracy and prevents errors that can occur when relying on memory over time.
Question 6: Which information is most important to include when documenting a resident's fall?
- The nurse aide's opinion on why the fall happened
- The time, location, resident condition before and after, and who was notified (Correct answer)
- Only the injuries sustained during the fall
- The names of witnesses and their personal contact information
Correct answer: The time, location, resident condition before and after, and who was notified
Complete fall documentation includes circumstances, resident status, injuries, and notification chain to support follow-up care.
Question 7: A resident's intake and output (I&O) record is used primarily to:
- Track medication administration times
- Monitor fluid balance and kidney function (Correct answer)
- Document the resident's daily activity level
- Record meal preferences and dietary restrictions
Correct answer: Monitor fluid balance and kidney function
I&O records help the care team identify fluid imbalances that could indicate kidney problems or dehydration.
INACE Documentation and Record Keeping 2
When a nurse aide makes an error in a written medical record, what is the correct procedure?