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
Which of the following changes in a resident's condition requires immediate documentation AND reporting?
Answer: The resident's temperature rises to 102°F
A significant change such as a high fever must be documented and reported to the nurse immediately as it may indicate a serious medical issue.
In healthcare documentation, the term 'ADL' refers to:
Answer: Activities of Daily Living
ADL stands for Activities of Daily Living, which include tasks such as bathing, dressing, eating, and mobility that are regularly documented in care records.
If a nurse aide witnesses another staff member falsifying a resident's documentation, the aide should:
Answer: Report the incident to the supervisor or appropriate authority
Falsifying medical records is illegal and endangers residents; reporting such behavior to a supervisor or authority is both an ethical and legal obligation.
When is it appropriate to leave a blank space in a paper medical record form?
Answer: When the information is not applicable, mark it N/A; never leave unexplained blanks
Unexplained blank spaces in medical records can be misinterpreted or filled in incorrectly later; marking N/A clarifies that the item was intentionally not applicable.
A resident has a Do Not Resuscitate (DNR) order. Where should this information most critically be documented?
Answer: Prominently in the medical record and care plan, per facility policy
A DNR order must be clearly documented in the medical record and care plan so all care team members are aware during any emergency.
What is the significance of using only approved abbreviations in medical documentation?
Answer: Unapproved abbreviations can be misread, leading to dangerous errors in care
Using non-standard abbreviations risks misinterpretation by other staff, which can result in serious errors in patient care and treatment.
How long are healthcare facilities typically required to retain resident medical records after discharge or death?
Answer: Per state law, often 5–10 years or longer
Medical record retention requirements vary by state but typically mandate keeping records for 5–10 years or longer after discharge or death to support legal, insurance, and care continuity needs.