Documentation and Reporting Flashcards

A new physician order changes a resident's insulin dose. Before documenting and administering the new dose, the QMA should:

Answer: Confirm the written or verified order exists on the MAR before proceeding

A QMA must verify that a written or verified order appears on the MAR before documenting and administering any changed dose.

Which of the following is an example of OBJECTIVE data that a QMA should document after insulin administration?

Answer: Blood glucose reading of 95 mg/dL at 0730

Objective data consists of measurable, observable facts such as a specific blood glucose value, not interpretations or feelings.

A QMA discovers a discrepancy between the insulin remaining in the pen and the units documented on the MAR. What is the correct action?

Answer: Report the discrepancy to the charge nurse and document the report

Discrepancies between insulin supply and MAR records must be reported to the charge nurse immediately and documented, as this may indicate a medication diversion or error.

When using a sliding scale insulin protocol, what TWO pieces of data must be documented together on the MAR?

Answer: Blood glucose reading and corresponding insulin units administered

Sliding scale documentation requires the blood glucose value that triggered the dose and the exact number of units administered to show clinical reasoning.

A QMA must report a change in a resident's condition after insulin administration. To which person should this FIRST be reported?

Answer: The charge nurse or supervising nurse

Any change in condition following insulin administration must be reported immediately to the charge nurse, who is responsible for clinical decision-making.

Which of the following constitutes falsification of medical records?

Answer: Initialing for a dose that was not administered

Documenting that a medication was given when it was not is falsification of medical records, which is illegal and grounds for license revocation.

After a resident is transferred to the hospital following a hypoglycemic episode, the QMA should ensure which document accompanies the transfer?

Answer: A copy of the MAR and blood glucose log relevant to the episode

Transfer documentation must include the MAR and glucose log so the receiving facility has accurate medication and clinical data to continue safe care.