Documentation & Health Records Flashcards
7 cards from real Low Risk Neonatal Nurse Exam practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation & Health Records flashcards as text
A nurse forgot to chart a medication given to an infant two hours ago. What is the correct way to document it?
Answer: Enter it now, labeled as a late entry with the current date/time and reference to the actual time given
Late entries must be clearly labeled, carry the current date and time, and reference the time of the event.
Which abbreviation is on The Joint Commission's 'Do Not Use' list?
Answer: U for units
'U' can be mistaken for 0, 4, or cc, so 'unit' must be written out.
Which documentation practice correctly fixes a charting error on a paper record?
Answer: Draw a single line through it, write 'error', and add initials, date and time
A single line keeps the original legible and shows who corrected it and when.
At what times is the Apgar score routinely recorded?
Answer: 1 minute and 5 minutes
Apgar scores are assigned at 1 and 5 minutes, with further scores every 5 minutes up to 20 minutes if the 5-minute score is below 7.
Under HIPAA, who may generally access a newborn's health record?
Answer: The parent or legal guardian acting as personal representative
Parents are the infant's personal representatives and may access the record, subject to law.
In what unit should a newborn's birth weight be documented to ensure accuracy?
Answer: Grams
Grams are the standard unit for neonatal weights because dosing and trends depend on small differences.
When must the infant and mother ID bands be verified and documented as matching?
Answer: Whenever the infant leaves the mother's side, and at discharge
Matching bands are checked before the infant leaves the delivery area, at each separation or reunion, and at discharge.
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