CNA Documentation and Reporting Quiz

Which of the following is a key component of effective patient care documentation?

• Using medical jargon to ensure accuracy

• Recording information in a timely manner

• Including personal opinions about the patient

• Writing in cursive for better readability

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DOK Level 2: Skill/Concept

When documenting patient care, why is it important to use objective language?

• To make the document more interesting

• To ensure clarity and accuracy

• To impress other healthcare professionals

• To fill up more space in the report

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DOK Level 2: Skill/Concept

Which of the following best describes the purpose of reporting patient observations?

• To entertain the healthcare team

• To provide a basis for patient care decisions

• To create a narrative for the patient's family

• To fulfill legal requirements only

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DOK Level 2: Skill/Concept

What is the most appropriate action if a CNA notices a change in a patient's condition?

• Wait until the end of the shift to report it

• Document it and report it immediately to a nurse

• Ignore it if the patient is not complaining

• Discuss it with other CNAs first

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DOK Level 2: Skill/Concept

Which of the following should be included in a patient's care documentation?

• The CNA's personal feelings about the patient

• Objective observations and care provided

• Predictions about the patient's future health

• Unverified information from the patient's family

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DOK Level 2: Skill/Concept

How should a CNA document a patient's refusal of care?

• Ignore the refusal and proceed with care

• Note the refusal and inform the nurse

• Convince the patient to accept care and not document it

• Document it only if the patient changes their mind

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DOK Level 2: Skill/Concept

Which of the following is an example of subjective information in patient care documentation?

• The patient has a temperature of 101°F

• The patient states they feel dizzy

• The patient has a pulse rate of 80 bpm

• The patient is wearing a blue gown

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DOK Level 2: Skill/Concept

What should a CNA do if they make an error in patient documentation?

• Erase the error and write over it

• Cross it out with a single line and initial it

• Ignore the error and continue

• Use white-out to cover the error

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DOK Level 2: Skill/Concept

Which of the following is a correct practice when reporting patient observations?

• Reporting only positive changes

• Reporting all observations, both positive and negative

• Reporting only when asked by a nurse

• Reporting only if the patient requests it

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DOK Level 2: Skill/Concept

During her shift, Sophia notices something unusual about a patient's condition. What should she do if she is unsure about how to document this specific observation?

• Guess and document it anyway

• Ask a nurse for guidance

• Leave it out of the documentation

• Document it as they see fit

Tags

DOK Level 2: Skill/Concept