Monitoring and Documentation Flashcards

A resident's blood glucose log must be kept for how long according to most state long-term care regulations?

Answer: At least as long as required by the facility's medical records retention policy (often years)

Medical records, including glucose logs, must be retained per state and federal regulations, typically for several years after care ends.

Which of the following is an example of a late entry in the medical record?

Answer: Documenting at 3 PM that insulin was given at 8 AM because the original entry was missed

A late entry is made after a significant time delay; it must be clearly labeled as 'late entry' with the current date/time and the time the care was actually provided.

The QMA notices that a co-worker has been documenting insulin as given before actually administering it. This is:

Answer: A serious documentation violation that must be reported to the nurse or supervisor

Pre-documenting medication administration is falsification of medical records and a serious safety violation that must be reported.

When monitoring a resident after insulin injection, which vital sign change would MOST concern the QMA regarding hypoglycemia?

Answer: Heart rate increasing to 110 bpm with diaphoresis

Tachycardia (elevated heart rate) combined with diaphoresis (sweating) are classic autonomic signs of hypoglycemia requiring immediate action.

A resident on insulin is NPO (nothing by mouth) before a morning procedure. The QMA should:

Answer: Check blood glucose, withhold insulin, and notify the nurse for specific NPO insulin orders

NPO status changes insulin requirements significantly; the QMA must check glucose, withhold the dose, and notify the nurse for specific orders.

Which of the following BEST describes the QMA's role in identifying and reporting blood glucose trends?

Answer: Document each reading accurately and report patterns of highs or lows to the nurse

QMAs are the front-line observers; accurate documentation and trend reporting to nurses enables timely clinical interventions.

When a resident's blood glucose is within the normal range and insulin is administered per the sliding scale, the QMA's documentation should include:

Answer: Glucose value, time checked, insulin type/dose/site/time administered, and resident response

Complete insulin documentation requires the glucose reading, when it was taken, and full details of insulin administration including type, dose, site, and time.