Understanding Medical Documentation Flashcards

When must a nursing assistant complete an incident report?

Answer: Whenever an unexpected event occurs, such as a fall, medication error, or resident elopement

Incident reports must be completed any time an unexpected or unusual event occurs, regardless of whether injury resulted.

After a resident falls, the nursing assistant should document in the medical record:

Answer: Factual observations such as where the resident was found, their condition, and who was notified

Factual, objective documentation of what was observed and what actions were taken is required in the resident's chart after any incident.

An incident report is considered a:

Answer: Quality improvement tool kept separately from the medical record

Incident reports are internal quality improvement documents and are generally not filed in the resident's medical record.

Which of the following would NOT typically require an incident report?

Answer: A resident refusing their afternoon snack

A resident refusing a snack is a routine preference or refusal that should be documented in the chart but does not require an incident report.

A nursing assistant witnesses a resident fall. Who should be notified FIRST?

Answer: The charge nurse

The charge nurse must be notified immediately so the resident can be assessed and appropriate care provided.

Resident elopement (leaving the facility without authorization) must be documented and reported because it is:

Answer: A serious safety incident that triggers mandatory reporting protocols

Elopement is a critical safety incident requiring immediate action, documentation, and reporting to the nurse, administrator, and often to state authorities.

When documenting a skin tear found during care, the nursing assistant should include:

Answer: Location, size, color, surrounding skin condition, and who was notified

Thorough wound documentation includes location, size, appearance, surrounding tissue condition, and notification of the supervising nurse.