Questions and Answers
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).
charted, done
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?
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Should a nursing assistant use correction fluid (White-Out) to correct a mistake?
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What is the purpose of charting?
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Who fills out the Minimum Data Set (MDS)/care plan?
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Give an example of subjective and objective reporting.
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It is important to use ________ _________ when describing an emotional statement made by a resident.
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Is it acceptable for a nursing assistant to chart a procedure before it has been done?
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If a resident's roommate tells you something, how should you chart that?
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How do you sign the chart once you are done writing your observations and the procedures you have performed?
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Is delirium a part of normal aging?
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How long could it take a resident to recover from a bout of delirium due to an illness?
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What percentage of residents in nursing facilities show signs and symptoms of decline in intellectual functioning?
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Which of the following is the correct way for Susan Metz, certified nurse assistant, to sign her name?
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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?
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Study Notes
Charting on Medical Records
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Resident's chart is a legal document; all information is confidential.
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Important rule in healthcare: "If it's not charted, then it was not done."
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Chart only facts; avoid including opinions to maintain objectivity.
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Use a black or blue ballpoint pen for charting medical records.
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Do not use correction fluid for mistakes; indicate errors by crossing out the entry, writing "mistaken entry," and initialing it.
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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
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The Minimum Data Set (MDS) and care plan are filled out by an RN or LPN.
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Objective Reporting example: "Found Mrs. Smith seated on the floor beside the bed."
- Subjective Reporting example: "Mrs. Smith fell on the floor."
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Use direct quotes when documenting residents' emotional statements.
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Nursing assistants should never chart a procedure before it has been performed to avoid misinformation.
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Information received from a resident's roommate should be recorded as secondhand information.
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Sign charts with first initial, last name, and job title.
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Delirium is not a part of normal aging; its onset can vary based on health status and severity of underlying causes.
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Recovery from delirium due to illness can take several weeks for cognitive abilities to return to pre-delirium status.
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60% of residents in nursing facilities show signs of decline in intellectual functioning.
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Correct way to sign includes last name, first initial, and job title (e.g., B. S. Metz, CNA).
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Correcting chart errors involves drawing one line through the mistake, writing "mistaken entry," and initialing it.
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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.
