UNAR Understanding Medical Documentation 2 — Questions and Answers
Question 1: A nursing assistant forgot to document a resident's vital signs at 8 AM. It is now 11 AM. What is the correct way to handle this?
- Skip the entry since too much time has passed
- Write a late entry with the current time and note it as a late entry for 8 AM (Correct answer)
- Change the time on the chart to 8 AM so it looks timely
- Ask another CNA to sign the 8 AM entry
Correct answer: Write a late entry with the current time and note it as a late entry for 8 AM
A late entry is acceptable and must be labeled as such, documenting both the time of the actual event and the time of the entry.
Question 2: Which action is considered falsification of medical records?
- Writing a late entry labeled as such
- Signing only your own entries
- Documenting care that was not actually performed (Correct answer)
- Correcting an error with a single line
Correct answer: Documenting care that was not actually performed
Documenting care that was not given is falsification and is illegal, unethical, and grounds for license revocation.
Question 3: When making a correction in a paper medical chart, the nursing assistant should:
- Use correction fluid to cover the error and write over it
- Draw a single line through the error, initial it, date it, and write the correct information (Correct answer)
- Tear out the page and rewrite it
- Erase the error completely
Correct answer: Draw a single line through the error, initial it, date it, and write the correct information
A single line through the error with initials and date preserves the original entry and maintains the legal integrity of the record.
Question 4: How soon after providing care should a nursing assistant document the care given?
- At the end of the shift only
- Within 24 hours
- As soon as possible after the care is given (Correct answer)
- Only after the charge nurse reviews it
Correct answer: As soon as possible after the care is given
Documenting as soon as possible after care is given ensures accuracy and reduces the risk of errors or omissions.
Question 5: A CNA documents a resident's meal intake as '100%' when the resident only ate about half the meal. This is an example of:
- Acceptable rounding in documentation
- Falsification of medical records (Correct answer)
- A late entry
- An objective observation
Correct answer: Falsification of medical records
Documenting inaccurate intake percentages is falsification and can affect the resident's care plan and nutritional management.
Question 6: Which of the following best describes 'flow sheets' used in nursing facilities?
- Physician order forms
- Preprinted forms used to record routine, repetitive care tasks quickly (Correct answer)
- Emergency contact lists
- Insurance billing records
Correct answer: Preprinted forms used to record routine, repetitive care tasks quickly
Flow sheets are preprinted tools that allow staff to document routine care efficiently by checking boxes or entering brief data.
Question 7: When documenting in the medical record, a nursing assistant should NEVER:
- Use blue or black ink
- Sign with their name and title
- Leave blank spaces in chart entries (Correct answer)
- Use clear, concise language
Correct answer: Leave blank spaces in chart entries
Blank spaces in documentation can be filled in later by someone else, creating a legal and safety risk.
UNAR Understanding Medical Documentation 2
A nursing assistant forgot to document a resident's vital signs at 8 AM.
It is now 11 AM.
What is the correct way to handle this?