Documentation and Record Keeping Flashcards
7 cards from real TRIVIUM practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation and Record Keeping flashcards as text
When a nurse aide makes an error in a paper medical record, what is the correct procedure?
Answer: Draw a single line through the error, write 'error,' initial, and date it
The correct method is to draw one line through the error, write 'error,' and add your initials and date so the original entry remains readable.
What does the abbreviation 'NPO' mean in medical documentation?
Answer: Nothing by mouth
NPO stands for 'nil per os,' a Latin phrase meaning nothing by mouth, often ordered before surgery or certain procedures.
Which of the following is an example of objective information that should be documented?
Answer: The patient's blood pressure is 130/85 mmHg
Objective information is measurable and observable, such as a specific blood pressure reading, rather than subjective interpretations.
How should a nurse aide document care that has not yet been provided?
Answer: Leave the chart blank until care is given, then document
Care should never be documented before it is performed; documentation must accurately reflect what has actually been done.
A resident's medical record is a legal document. This means:
Answer: Accurate, complete, and timely entries are legally required
Because the medical record is a legal document, all entries must be accurate, complete, and made in a timely manner to protect both the patient and the caregiver.
What information should be included when documenting a resident's intake and output (I&O)?
Answer: The time, type, and amount of each intake and output
Accurate I&O documentation requires recording the time, type of fluid, and specific amount for each instance of intake and output.
Which of the following best describes the purpose of a flow sheet in healthcare documentation?
Answer: To provide a quick visual record of routine care tasks over time
Flow sheets allow staff to quickly record and review recurring care tasks such as vital signs, repositioning, or hygiene at regular intervals.