Question

name: 23

1. explain documentation and describe related terms and forms

multiple choice

1. the large amount of time that a nursing - assistant spends with residents will allow her to

(a) diagnose illnesses
(b) determine treatments
(c) notice things about residents that other care team members may not notice
(d) give medical advice

1. which of the following statements is true of a residents medical chart?

(a) a medical chart is the legal record of a residents care.
(b) not all care needs to be documented.
(c) documentation can be put off until the next day if a nursing assistant is busy.
(d) medical charts are not considered legal documents.

1. when should care be documented?

(a) before care is given
(b) immediately after care is given
(c) at the end of the day
(d) whenever there is time
short answer
convert the following times to military time:

1. 2:10 p.m.
2. 4:30 a.m.
3. 10:00 a.m.
4. 8:25 p.m.

convert the following times to regular time:

1. 0600
2. 2320
3. 1927
4. 1800
5. describe incident reporting and recording

multiple choice

1. an incident is

(a) an accident or unexpected event in the course of care
(b) any interaction between residents and staff
(c) a normal part of facility routines
(d) any event in a residents day

1. which of the following would be considered an incident?

(a) a resident complains of a headache.
(b) a resident falls but is okay afterward.
(c) a resident wants to watch tv in the common living area.
(d) a resident needs to be transferred from his bed to a chair.

1. incidents should be reported to

(a) the residents family
(b) the charge nurse
(c) all staff on duty at the time of the incident
(d) the doctor on call
true or false

1. ___ documentation of incidents helps protect the resident, the employer, and individual staff members.
2. ___ the information in an incident report is confidential.
3. ___ if an na does not actually see an incident but arrives after it has already occurred, she should document what she thinks happened.
4. ___ the documentation of an incident should include who the nursing assistant thinks could be responsible for the incident.
5. ___ incident reports should be factual.
6. ___ if a resident who is supposed to eat a low - sodium meal eats a regular, unrestricted meal, an incident report does not need to be completed.
7. ___ if an na receives an injury on the job, he should file an incident report.

Explanation:

1. A nursing assistant's close - contact time allows noticing details others may miss.
2. A medical chart is a legal record of care.
3. Care should be documented immediately after being given for accuracy.
4. To convert p.m. times to military time, add 1200 to afternoon/evening times.
5. 0600 in military time is 6:00 a.m. in regular time.
6. An incident is an accident or unexpected event in care. A fall, even if the resident is okay, is an incident.
7. Incidents should be reported to the charge nurse.
8. Incident documentation protects all parties.
9. Incident report info is confidential.
10. Only document what is known, not speculation.
11. Incident documentation should be factual, not assign blame prematurely.
12. A resident eating the wrong meal is an incident.
13. An on - the - job injury for an NA requires an incident report.

Answer:

1. C. Notice things about residents that other care team members may not notice
2. A. A medical chart is the legal record of a resident's care.
3. B. Immediately after care is given
4. 1410
5. 0430
6. 1000
7. 2025
8. 6:00 a.m.
9. 11:12 p.m.
10. 7:27 p.m.
11. 6:00 p.m.
12. A. An accident or unexpected event in the course of care
13. B. A resident falls but is okay afterward.
14. B. The charge nurse
15. True
16. True
17. False
18. False
19. True
20. True
21. True