Documentation and Record Keeping Flashcards
6 cards from real STRTP practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Documentation and Record Keeping flashcards as text
When an ISP is revised for an STRTP resident, who must be involved in the revision process according to California guidelines?
Answer: The resident (age-appropriately), the placing agency, and the clinical team
ISP revisions must be collaborative, involving the resident to the extent possible, the placing agency, and the facility's clinical and care team.
Which type of documentation must be completed for every medication error in an STRTP?
Answer: An incident report filed in the resident's record and reported to the placing agency
All medication errors must be formally documented in an incident report and communicated to the placing agency regardless of whether harm occurred.
An STRTP's health and medical records for a resident should include which of the following at minimum?
Answer: Immunization records, physical examination results, medication logs, and allergy information
Complete health records must include immunizations, physical exam findings, allergy information, and all medication administration records.
If a DSS licensing analyst requests a resident's records during an inspection, the STRTP administrator must:
Answer: Provide the requested records in a timely manner as part of the licensing compliance obligation
DSS licensing analysts have the legal authority to review facility records during inspections, and the STRTP is obligated to provide them in a timely manner.
Electronic records in an STRTP must meet which security standard to protect resident confidentiality?
Answer: Controlled access with unique user logins, audit trails, and encryption of sensitive data
Electronic health records must have access controls, audit logs to track who accessed records and when, and encryption to protect sensitive resident information.
A resident's ISP goal in an STRTP must be written in what manner to be clinically meaningful?
Answer: As a specific, measurable, achievable, relevant, and time-bound (SMART) goal
Effective ISP goals follow the SMART framework to ensure they are actionable, trackable, and genuinely guide the resident's progress.
How this page was made: written with AI tools and published by Nathan Beja, founder of Practice Test Geeks, who is responsible for its content. Exam facts are checked against the official sources listed below. Not reviewed by a subject-matter expert. Editorial policy
Sources & references
Exam facts on this page (fees, format, dates, passing scores) are checked against these official sources; the date is our last check. Editorial policy
- cdss.ca.gov — Test delivery, exam format, passing score, registration deadline, retake fee, time limit, score validity, fees, score release, exam dates · verified Oct 2026