INACE Documentation and Record Keeping 3 — Questions and Answers
Question 1: Which of the following statements about medical records is correct?
- Medical records belong to the nurse aide who wrote them
- Medical records are legal documents that can be used in court (Correct answer)
- Medical records may be shared freely with any staff member
- Medical records should be stored at the nurse aide's workstation
Correct answer: Medical records are legal documents that can be used in court
Medical records are legal documents and must be treated with care, accuracy, and confidentiality.
Question 2: What should a nurse aide do if asked to sign a document for care that was never provided?
- Sign it since the charge nurse asked
- Refuse to sign and report the request to a supervisor (Correct answer)
- Sign it but note a disagreement in a separate document
- Sign it and then provide the care afterward
Correct answer: Refuse to sign and report the request to a supervisor
Signing for care not provided is falsification of medical records, which is both unethical and illegal.
Question 3: When documenting a resident's complaint of pain, which entry is most appropriate?
- 'Resident complained of pain — gave comfort.'
- 'Resident stated pain is 7/10 in left knee; charge nurse notified.' (Correct answer)
- 'Resident seems to exaggerate pain levels frequently.'
- 'Pain was managed appropriately during shift.'
Correct answer: 'Resident stated pain is 7/10 in left knee; charge nurse notified.'
Accurate documentation includes the resident's own words, location, severity rating, and the actions taken.
Question 4: Which of the following is an example of subjective documentation that should be avoided?
- 'Resident's skin is warm and dry.'
- 'Resident ate 75% of lunch tray.'
- 'Resident seems to be in a bad mood today.' (Correct answer)
- 'Resident ambulated 50 feet with a walker.'
Correct answer: 'Resident seems to be in a bad mood today.'
Saying a resident 'seems' to be in a bad mood is an interpretation, not a factual observation.
Question 5: A nurse aide forgot to document care provided during the morning shift. What is the correct action?
- Do not document it since too much time has passed
- Make a late entry, clearly labeled with the current date/time and the time care was provided (Correct answer)
- Ask another aide to document the care
- Simply add the entry without noting it is a late entry
Correct answer: Make a late entry, clearly labeled with the current date/time and the time care was provided
Late entries are acceptable when clearly labeled, preserving the accuracy and completeness of the record.
Question 6: Who is ultimately responsible for ensuring that documentation in a resident's chart is accurate?
- The facility's medical records department
- Each individual who provides and documents care (Correct answer)
- The charge nurse on duty
- The facility administrator
Correct answer: Each individual who provides and documents care
Every care provider is individually responsible for the accuracy and completeness of their own documentation.
Question 7: What is the main purpose of a minimum data set (MDS) in long-term care facilities?
- To track nurse aide work hours and schedules
- To provide a standardized assessment of resident needs and care planning (Correct answer)
- To document incident reports for state inspectors
- To bill Medicare for services provided
Correct answer: To provide a standardized assessment of resident needs and care planning
The MDS is a federally mandated assessment tool that guides care planning and ensures residents receive appropriate services.
INACE Documentation and Record Keeping 3
Which of the following statements about medical records is correct?