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
Under HIPAA regulations, a nurse aide may share a resident's health information with:
Answer: Members of the care team directly involved in the resident's care
HIPAA permits sharing health information only with those directly involved in the patient's care on a need-to-know basis.
What should a nurse aide do if they are unsure how to document a specific observation?
Answer: Ask the charge nurse or supervisor for guidance
When unsure about documentation, the nurse aide should consult the charge nurse or supervisor to ensure accuracy and compliance.
Which of the following is NOT an acceptable reason to review a resident's medical record?
Answer: To satisfy personal curiosity about the resident's diagnosis
Accessing a resident's medical record out of personal curiosity violates HIPAA and the resident's right to privacy.
When documenting the time of care in a 24-hour clock format, 3:30 PM would be written as:
Answer: 1530
In 24-hour (military) time, PM hours are expressed by adding 12 to the hour, so 3:30 PM becomes 1530.
Which document outlines the individualized plan for a resident's care and is used to guide daily documentation?
Answer: Care plan
The care plan is a personalized document that directs all aspects of a resident's care and serves as the basis for consistent documentation.
A nurse aide notices a resident has a new skin tear that was not previously documented. What should be done first?
Answer: Report it to the charge nurse immediately and document the observation
New skin injuries must be reported to the charge nurse immediately and documented promptly to ensure appropriate treatment and accountability.
What is the main purpose of the Minimum Data Set (MDS) in long-term care documentation?
Answer: To standardize comprehensive resident assessment for care planning and reimbursement
The MDS is a federally mandated assessment tool used in skilled nursing facilities to evaluate residents comprehensively and guide care planning and funding.