Documentation and Reporting Flashcards

A QMA checks a resident's blood glucose, and the glucometer displays the reading "HI," indicating the value is above the meter's measurable range. What is the QMA's IMMEDIATE responsibility?

Answer: Immediately notify the licensed nurse of the critical result.

A "HI" reading indicates severe hyperglycemia, which is a potential medical emergency. The QMA's scope of practice requires them to report critical findings to the licensed nurse immediately for further assessment and intervention. The nurse will determine the appropriate course of action, which may be beyond the QMA's scope.

Which of the following elements is ESSENTIAL for a QMA to document on the Medication Administration Record (MAR) immediately after administering an insulin injection?

Answer: The specific anatomical site used for the injection.

Proper documentation after insulin administration must include the date, time, dose given, the resident's blood sugar level, and the specific site of injection (e.g., right abdomen, left upper arm). [14, 15] Recording the site is vital for ensuring proper site rotation, preventing skin complications like lipohypertrophy, and providing a complete record for continuity of care. [13]

A resident, who is alert and oriented, refuses their scheduled pre-meal fingerstick blood glucose check. The QMA cannot administer the sliding scale insulin without this reading. What is the most appropriate action for the QMA to take regarding documentation and reporting?

Answer: Document the refusal on the MAR according to facility policy and immediately report the refusal to the licensed nurse.

Residents have the right to refuse care and treatment. The QMA's primary responsibility is to report the refusal to the licensed nurse promptly and to document the event accurately on the MAR according to facility policy. [8, 18] This typically involves initialing, circling the time, and writing "refused" or a similar notation, often with a detailed note on the back of the MAR or in the nurse's notes. [17]

After administering insulin, a QMA observes that the resident has developed significant redness and swelling at the injection site. Which of the following best describes the QMA's responsibility for reporting and documentation?

Answer: Report the findings to the licensed nurse immediately and document the observation and the notification in the resident's record.

Redness and swelling at an injection site are signs of a potential adverse reaction which requires immediate assessment by a licensed nurse. The QMA must report this observation to the nurse without delay. The QMA must also document their objective findings and the fact that they reported it to the nurse, including the time of notification and the nurse's name. [8]

Why is it critical for a QMA to document a blood glucose reading and any corresponding insulin dose at the exact time the event occurs?

Answer: To create a legal record that accurately reflects the timing of care and supports ongoing clinical decision-making.

The Medication Administration Record (MAR) is a legal document. Documenting in real-time ensures accuracy and provides a clear and correct timeline of the resident's status, interventions, and response. This information is critical for the entire healthcare team to make informed decisions about the resident's plan of care and is essential for legal and regulatory compliance. [18]

A QMA realizes they have documented the administration of 6 units of insulin on the MAR, but they actually administered the correct dose of 4 units per the sliding scale order. What is the correct procedure for the QMA to follow to correct this documentation error?

Answer: Draw a single line through the error, write "error" or "mistaken entry," add their initials, and then write the correct information. [3, 17]

Medical records must be corrected in a way that maintains the integrity and legibility of the original entry. The standard, legally-defensible procedure is to draw a single line through the incorrect entry, write "error" or "mistaken entry" nearby, and add the initials of the person making the correction. [3, 17, 19] The error should also be reported to the licensed nurse. Using white-out, erasing, or scribbling out entries is prohibited as it can be interpreted as an attempt to falsify the record. [3]