Podcast
Questions and Answers
As a nursing assistant it is important to remember that the residents chart is a _________ __________.
As a nursing assistant it is important to remember that the residents chart is a _________ __________.
legal document
A common rule in health care is 'if it’s not __________(1), then it was not _________(2).
A common rule in health care is 'if it’s not __________(1), then it was not _________(2).
charted, done
It is important to be objective and to chart only the ___________(1); don't document your ____________(2).
It is important to be objective and to chart only the ___________(1); don't document your ____________(2).
facts, opinions
What type of ink pen should be used for charting medical records?
What type of ink pen should be used for charting medical records?
Signup and view all the answers
Should a nursing assistant use correction fluid (White-Out) to correct a mistake?
Should a nursing assistant use correction fluid (White-Out) to correct a mistake?
Signup and view all the answers
What is the purpose of charting?
What is the purpose of charting?
Signup and view all the answers
Who fills out the Minimum Data Set (MDS)/care plan?
Who fills out the Minimum Data Set (MDS)/care plan?
Signup and view all the answers
Give an example of subjective and objective reporting.
Give an example of subjective and objective reporting.
Signup and view all the answers
It is important to use ________ _________ when describing an emotional statement made by a resident.
It is important to use ________ _________ when describing an emotional statement made by a resident.
Signup and view all the answers
Is it acceptable for a nursing assistant to chart a procedure before it has been done?
Is it acceptable for a nursing assistant to chart a procedure before it has been done?
Signup and view all the answers
If a resident's roommate tells you something, how should you chart that?
If a resident's roommate tells you something, how should you chart that?
Signup and view all the answers
How do you sign the chart once you are done writing your observations and the procedures you have performed?
How do you sign the chart once you are done writing your observations and the procedures you have performed?
Signup and view all the answers
Is delirium a part of normal aging?
Is delirium a part of normal aging?
Signup and view all the answers
How long could it take a resident to recover from a bout of delirium due to an illness?
How long could it take a resident to recover from a bout of delirium due to an illness?
Signup and view all the answers
What percentage of residents in nursing facilities show signs and symptoms of decline in intellectual functioning?
What percentage of residents in nursing facilities show signs and symptoms of decline in intellectual functioning?
Signup and view all the answers
Which of the following is the correct way for Susan Metz, certified nurse assistant, to sign her name?
Which of the following is the correct way for Susan Metz, certified nurse assistant, to sign her name?
Signup and view all the answers
You have made an error in charting on a resident's chart. Which one of the following examples below is the procedure for correcting it?
You have made an error in charting on a resident's chart. Which one of the following examples below is the procedure for correcting it?
Signup and view all the answers
Study Notes
Charting on Medical Records
-
Resident's chart is a legal document; all information is confidential.
-
Important rule in healthcare: "If it's not charted, then it was not done."
-
Chart only facts; avoid including opinions to maintain objectivity.
-
Use a black or blue ballpoint pen for charting medical records.
-
Do not use correction fluid for mistakes; indicate errors by crossing out the entry, writing "mistaken entry," and initialing it.
-
Purpose of charting includes:
- Communication with the healthcare team
- Documenting care delivery
- Providing evidence for care received to agencies
- Supporting insurance claims and legal documentation
-
The Minimum Data Set (MDS) and care plan are filled out by an RN or LPN.
-
Objective Reporting example: "Found Mrs. Smith seated on the floor beside the bed."
- Subjective Reporting example: "Mrs. Smith fell on the floor."
-
Use direct quotes when documenting residents' emotional statements.
-
Nursing assistants should never chart a procedure before it has been performed to avoid misinformation.
-
Information received from a resident's roommate should be recorded as secondhand information.
-
Sign charts with first initial, last name, and job title.
-
Delirium is not a part of normal aging; its onset can vary based on health status and severity of underlying causes.
-
Recovery from delirium due to illness can take several weeks for cognitive abilities to return to pre-delirium status.
-
60% of residents in nursing facilities show signs of decline in intellectual functioning.
-
Correct way to sign includes last name, first initial, and job title (e.g., B. S. Metz, CNA).
-
Correcting chart errors involves drawing one line through the mistake, writing "mistaken entry," and initialing it.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Description
This quiz focuses on the essential principles of charting in medical records for nursing assistants. Understanding legal documents and the importance of accurate record-keeping is crucial for proper patient care. Test your knowledge and ensure you're equipped with the right charting skills.
