UNAR Understanding Medical Documentation 3 — Questions and Answers
Question 1: In medical documentation, the abbreviation 'PRN' means:
- Patient refused nutrition
- As needed (Correct answer)
- Pre-registered nurse
- Pain relief now
Correct 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.
Question 2: What does the abbreviation 'NPO' mean in a resident's care plan?
- No patient orders
- Nothing by mouth (Correct answer)
- Nighttime positioning only
- Non-prescription option
Correct answer: Nothing by mouth
NPO means 'nihil per os' (nothing by mouth) and restricts the resident from eating or drinking, often before a procedure.
Question 3: The abbreviation 'SOB' in medical charting refers to:
- Shortness of breath (Correct answer)
- Side of bed
- Significant observed behavior
- Sudden onset bleeding
Correct answer: Shortness of breath
SOB stands for shortness of breath and is an important clinical finding that must be documented and reported promptly.
Question 4: When a nursing assistant charts 'resident ambulated 20 feet with walker, tolerated well,' this is an example of:
- Subjective documentation
- An incident report
- Objective, factual documentation (Correct answer)
- A physician progress note
Correct answer: Objective, factual documentation
Objective documentation records specific, measurable facts observed by the caregiver without interpretation or opinion.
Question 5: Which of the following is an example of SUBJECTIVE documentation?
- BP 138/88 at 0900
- Resident seems unhappy today (Correct answer)
- Resident ate 75% of lunch
- Resident ambulated 30 feet
Correct answer: Resident seems unhappy today
Subjective documentation reflects the caregiver's opinion or interpretation rather than observable, measurable facts.
Question 6: What does 'I&O' stand for in medical documentation?
- Instructions and orders
- Intake and output (Correct answer)
- Injury and observation
- Information and orientation
Correct answer: Intake and output
I&O stands for intake and output, which tracks all fluids consumed and excreted to monitor fluid balance.
Question 7: The medical abbreviation 'ADL' refers to:
- Acute disease level
- Activities of daily living (Correct answer)
- Admission documentation list
- Advanced directive language
Correct 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.
UNAR Understanding Medical Documentation 3
In medical documentation, the abbreviation 'PRN' means: