Trivium Documentation and Record Keeping 3 — Questions and Answers
Question 1: Under HIPAA regulations, a nurse aide may share a resident's health information with:
- Any hospital staff member who asks
- The resident's neighbor who claims to be a friend
- Members of the care team directly involved in the resident's care (Correct answer)
- A local news reporter covering a health story
Correct 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.
Question 2: What should a nurse aide do if they are unsure how to document a specific observation?
- Skip documenting it to avoid mistakes
- Ask the charge nurse or supervisor for guidance (Correct answer)
- Document it using their best guess
- Ask another nurse aide to document it for them
Correct 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.
Question 3: Which of the following is NOT an acceptable reason to review a resident's medical record?
- To provide appropriate care based on the care plan
- To communicate a change in condition to the nurse
- To satisfy personal curiosity about the resident's diagnosis (Correct answer)
- To confirm a resident's dietary restrictions before a meal
Correct 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.
Question 4: When documenting the time of care in a 24-hour clock format, 3:30 PM would be written as:
- 3:30
- 0330
- 1530 (Correct answer)
- 15:3
Correct answer: 1530
In 24-hour (military) time, PM hours are expressed by adding 12 to the hour, so 3:30 PM becomes 1530.
Question 5: Which document outlines the individualized plan for a resident's care and is used to guide daily documentation?
- Incident report
- Care plan (Correct answer)
- Discharge summary
- Physician's progress note
Correct 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.
Question 6: A nurse aide notices a resident has a new skin tear that was not previously documented. What should be done first?
- Wait to see if it heals before reporting
- Report it to the charge nurse immediately and document the observation (Correct answer)
- Document it at the end of the shift
- Ask another aide if they noticed it
Correct 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.
Question 7: What is the main purpose of the Minimum Data Set (MDS) in long-term care documentation?
- To schedule staff shifts
- To standardize comprehensive resident assessment for care planning and reimbursement (Correct answer)
- To track staff training hours
- To document only physician orders
Correct 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.
Trivium Documentation and Record Keeping 3
Under HIPAA regulations, a nurse aide may share a resident's health information with: