Trivium Documentation and Record Keeping 2

Question 1

When a nurse aide makes an error in a paper medical record, what is the correct procedure?

Accepted Answer

Draw a single line through the error, write 'error,' initial, and date it

Answer

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?

Accepted Answer

Nothing by mouth

Answer

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?

Accepted Answer

The patient's blood pressure is 130/85 mmHg

Answer

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?

Accepted Answer

Leave the chart blank until care is given, then document

Answer

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:

Accepted Answer

Accurate, complete, and timely entries are legally required

Answer

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.

(Trivium) Trivium Health Care Exam Practice Test

(Trivium) Trivium Health Care Exam Practice Test

Trivium Documentation and Record Keeping 2