Skip to content

Home
login
Online Courses
FAQ
About Us
Contact

Home
login
Online Courses
FAQ
About Us
Contact

Medication/documentation exam

Welcome to your Medical Record Documentation and Legal Aspects Exam.

Please fill in your full name, and Email. We will email your results within 48 hours. You must get a 80% or better to pass. Good Luck.

Name

Email

1. Documentation in the medical records must be:

a. Complete

b. Correct

c. Done on time

d. All of the above

2. Some of the care that nursing assistants and home health aides must document are:

a. Baths, Showers, Oral care, Denture care, Foot care, Hair and nail care,

b. Urinary catheter care, Back care, Turning and positioning, Meal intake,

c. Fluid intake, Activities, like walking, Range of motion exercises if done,

d. Warm soaks, Cold applications

e. All of the above :

3. Some of the observations that nursing assistants and home health aides must document are:

a. Level of consciousness, Orientation to time, place and person, Height, Weight,

b. Urinary drainage bag output, Temperature, Pulse, Respiration rate, Blood pressure,

c. Blood glucose readings, Color of the skin, Warmth and characteristics of skin,

d. Things that the patient or resident says, Things that the patient or resident communicates

e. Behaviors, like anger and yelling

f. All of the above

4. Observations that nursing assistants and home health aides must document are, all things that you see, hear or feel, especially if it is not normal:

a. True

b. False

5. Some things that you should do in order to make sure that you treat these records as legal documents are:

a. Use blue or black ink unless you are using a computer or your hospital uses a special color ink for different shifts;

b. Write so that it can be read clearly. There should be no sloppy writing;

c. Date all of your notes;

d. Write the time that you write your note;

e. Sign your full name and title (CNA, HHA, etc);

f. Write only facts;

g. Keep all medical records in a safe and secure place;

h. Medical records are confidential. Do not tell anyone about what is in them unless they are taking care of the person.

i. All of the above

6. Some things that you should NOT do in order to make sure that you treat these records as legal documents are:

a. Use pencil or ink that can be erased;

b. Scribble things out if you make a mistake;

c. Use “White Out” or any other thing that covers up writing;

d. Chart before the fact. For example, do not check off a bath on the flow sheet until the bath is done;

e. Use an abbreviations unless they are accepted for use by your place of employment;

f. Allow anyone to touch or look at a medical record unless they are a healthcare provider taking care of that patient or resident;

g. All of the above

7. One Example of Writing Right is:

a. 7/15 8:30 AM: Morning care performed. Ambulate in corridor with walker. BM today. Took meds in morning slot. Red area on coccyx reported to nurse Sarah Smith. Sally Murphy, HHA

b. 7/15: Assisted with shave, foot soak. C/O earache + put drops in ears. Dana Byer, HHA

Children under the age of 8 but not infants.

c. Neither A or B

d. A or B :

8. An Example of What Not To Write is:

a. 7/15 9:00 AM: Assisted with shower. Nurse should have ordered shower chair as client was very shaky. This lady should be in a nursing home.. Cindy Smith, HHA

b. 7/15 11:00 AM Morning care done including shampoo. ROM exercises done. Absorbent underpaid changed 2x. Drank coffee and juice with help. No BM today. Martin Jones, HHA

c. A and B

d. A or B :

9. Reasons why the clinical record is important are:

a. It is the only written source for communication from you and reference for members of the health care team.

b. It supports payment for insurance coverage or denial for provided client care services.

c. It is the source for review and evaluation of the care provided.

d. It is a legal record.

e. It is important to maintaining organization certification or accreditation.

f. All of the above:

10. Some basic rules about documentation are:

a. Complete patient note for every shift or visit.

b. Finish the documentation as soon as the work is completed, e.g., as soon as the work is completed, write it on the visit/shift record prior to leaving.

c. Record any client refusal to have a task performed along with the reason if given on the visit note and make sure to notify your supervisor.

d. All of the above :

Time's up

Post navigation

← Previous Quiz

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

Comment *

Name*

Email*

Website

Save my name, email, and website in this browser for the next time I comment.

Join Our Community

Enter your email address to register to our newsletter subscription delivered on regular basis!

Our mission is to deliver high-quality services at competitive prices to achieve full client satisfaction. Accordingly, our company undertakes routine upgrades of all its courses, and adopts the latest technology for the delivery of both the existing products and the new additions.

Popular Courses

HHA Online Course
CNA Online Course
HHA & CNA Online Course
PCA Online Course
Caregiver Online Course
Terms of Service

Contact Info

Phone
(844)-556-8773
Email
Edu@nursingcertificationsonline.com

Copyright © 2024 NCO Academy

Powered by NCO Academy

Translate »

CNA Online Course Log-in

Enter Username :
Enter Password :

CPR Online Course Log-in

Enter Username :

Enter Password :

BFA Online Course Log-in

Enter Username :

Enter Password :

PCA Online Course Log-in

Enter Username :
Enter Password :

HHA Online Course Log-in

Enter Username :
Enter Password :