Trivium Documentation and Record Keeping 3

Question 1

Under HIPAA regulations, a nurse aide may share a resident's health information with:

Accepted Answer

Members of the care team directly involved in the resident's care

Answer

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?

Accepted Answer

Ask the charge nurse or supervisor for guidance

Answer

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?

Accepted Answer

To satisfy personal curiosity about the resident's diagnosis

Answer

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:

Accepted Answer

1530

Answer

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?

Accepted Answer

Care plan

Answer

The care plan is a personalized document that directs all aspects of a resident's care and serves as the basis for consistent documentation.

(Trivium) Trivium Health Care Exam Practice Test