Documentation and Reporting Flashcards

A QMA witnesses another QMA skip documentation after giving insulin. What is the appropriate response?

Answer: Encourage the colleague to complete their own documentation and report if they refuse

A QMA should encourage the colleague to complete their own documentation; if refused, the issue must be escalated to the nurse because altering or completing another's record is improper.

Which of the following BEST describes the purpose of maintaining accurate insulin documentation?

Answer: To ensure resident safety, legal accountability, and continuity of care

Accurate documentation protects resident safety, provides a legal record of care, and enables all team members to deliver consistent treatment.

A QMA administers insulin but forgets to document it until two hours later. How should the late entry be handled?

Answer: Write the entry with the current time and note 'late entry — actual time of administration was [time]'

Late entries are acceptable but must be clearly labeled 'late entry' with the actual time of administration so the record accurately reflects when care occurred.

Which information about injection site rotation is MOST important to document for a resident on long-term insulin therapy?

Answer: The specific anatomical site used each time to allow systematic rotation

Documenting the exact site used each time (e.g., right abdomen, left thigh) allows the care team to systematically rotate sites and prevent lipodystrophy.

A resident on insulin also takes oral medications. The QMA must document insulin on which record?

Answer: The Medication Administration Record (MAR) in the section designated for injectables/insulin

Insulin is documented on the official MAR in the injectable or insulin section, ensuring it is part of the legal medical record reviewed by all providers.

A physician order reads 'insulin lispro 5 units subcutaneous before meals.' The resident refuses breakfast. What should the QMA document?

Answer: That the dose was withheld due to resident meal refusal and the nurse was notified

Pre-meal rapid-acting insulin should generally not be given if a meal is refused due to hypoglycemia risk; the QMA must document the hold, reason, and nurse notification.

Which of the following is the BEST example of a complete and legally defensible insulin administration note?

Answer: 'Insulin lispro 6 units SQ, right outer thigh, BG 188 mg/dL, resident tolerated well, no complaints — J. Smith QMA 1415'

A legally defensible entry includes the drug, dose, route, site, blood glucose value, resident response, the QMA's name/credentials, and the exact time.