Understanding Medical Documentation Flashcards
7 cards from real UNAR practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Understanding Medical Documentation flashcards as text
In medical documentation, the abbreviation 'PRN' means:
Answer: As needed
PRN is a Latin abbreviation for 'pro re nata,' meaning 'as needed,' commonly used for medications or treatments given only when required.
What does the abbreviation 'NPO' mean in a resident's care plan?
Answer: Nothing by mouth
NPO means 'nihil per os' (nothing by mouth) and restricts the resident from eating or drinking, often before a procedure.
The abbreviation 'SOB' in medical charting refers to:
Answer: Shortness of breath
SOB stands for shortness of breath and is an important clinical finding that must be documented and reported promptly.
When a nursing assistant charts 'resident ambulated 20 feet with walker, tolerated well,' this is an example of:
Answer: Objective, factual documentation
Objective documentation records specific, measurable facts observed by the caregiver without interpretation or opinion.
Which of the following is an example of SUBJECTIVE documentation?
Answer: Resident seems unhappy today
Subjective documentation reflects the caregiver's opinion or interpretation rather than observable, measurable facts.
What does 'I&O' stand for in medical documentation?
Answer: Intake and output
I&O stands for intake and output, which tracks all fluids consumed and excreted to monitor fluid balance.
The medical abbreviation 'ADL' refers to:
Answer: Activities of daily living
ADLs are activities of daily living such as bathing, dressing, eating, and toileting that CNAs routinely assist with and document.
How this page was made: written with AI tools and published by Nathan Beja, founder of Practice Test Geeks, who is responsible for its content. Exam facts are checked against the official sources listed below. Not reviewed by a subject-matter expert. Editorial policy
Sources & references
Exam facts on this page (fees, format, dates, passing scores) are checked against these official sources; the date is our last check. Editorial policy
- utahcnaregistry.com — Test delivery, fees, exam format, passing score, score release, time limit, retake fee, renewal, retake policy, test dates · verified Oct 2026