UNAR Understanding Medical Documentation 2

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?

Accepted Answer

Write a late entry with the current time and note it as a late entry for 8 AM

Answer

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?

Accepted Answer

Documenting care that was not actually performed

Answer

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:

Accepted Answer

Draw a single line through the error, initial it, date it, and write the correct information

Answer

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?

Accepted Answer

As soon as possible after the care is given

Answer

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:

Accepted Answer

Falsification of medical records

Answer

Documenting inaccurate intake percentages is falsification and can affect the resident's care plan and nutritional management.

(UNAR) Utah Nursing Assistant Registry Practice Test