Trivium Documentation and Record Keeping 2 — Questions and Answers
Question 1: When a nurse aide makes an error in a paper medical record, what is the correct procedure?
- Use correction fluid to cover the mistake
- Draw a single line through the error, write 'error,' initial, and date it (Correct answer)
- Erase the error completely and rewrite the correct information
- Tear out the page and start over
Correct 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.
Question 2: What does the abbreviation 'NPO' mean in medical documentation?
- No physician orders
- Nothing by mouth (Correct answer)
- Normal pulse observed
- No patient output
Correct answer: Nothing by mouth
NPO stands for 'nil per os,' a Latin phrase meaning nothing by mouth, often ordered before surgery or certain procedures.
Question 3: Which of the following is an example of objective information that should be documented?
- The patient seems depressed today
- The patient appears to be in pain
- The patient's blood pressure is 130/85 mmHg (Correct answer)
- The patient looks like they didn't sleep well
Correct 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.
Question 4: How should a nurse aide document care that has not yet been provided?
- Document it in advance to save time
- Leave the chart blank until care is given, then document (Correct answer)
- Ask a coworker to document it
- Document it and mark it as 'planned'
Correct 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.
Question 5: A resident's medical record is a legal document. This means:
- Only doctors can read it
- Entries can be changed at any time without restriction
- Accurate, complete, and timely entries are legally required (Correct answer)
- It can be discarded after the resident leaves the facility
Correct 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.
Question 6: What information should be included when documenting a resident's intake and output (I&O)?
- Only the total daily fluid amount
- The time, type, and amount of each intake and output (Correct answer)
- A general estimate of fluids consumed
- Only output measurements, as intake is recorded separately
Correct 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.
Question 7: Which of the following best describes the purpose of a flow sheet in healthcare documentation?
- To record a physician's treatment orders
- To provide a quick visual record of routine care tasks over time (Correct answer)
- To document a patient's medical history
- To record medication administration only
Correct 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.
Trivium Documentation and Record Keeping 2
When a nurse aide makes an error in a paper medical record, what is the correct procedure?