HHA Medication/Documentation Legal Aspects Exam

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Question 1 of 10

1. Question

Some basic rules about documentation are:

Complete patient note for every shift or visit.
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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.
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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.
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All of the above
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Question 2 of 10

2. Question

Reasons why the clinical record is important are:

It is the only written source for communication from you and reference for members of the health care team.
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It supports payment for insurance coverage or denial for provided client care services.
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It is the source for review and evaluation of the care provided.
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It is important to maintaining organization certification or accreditation.
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All of the above
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Question 3 of 10

3. Question

An Example of What Not To Write is:

7/15 9:00 AM: Assisted with shower. Nurse should have ordered a shower chair, as the client was very shaky. This lady should be in a nursing home.. Cindy Smith, HHA
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7/15 11:00 AM Morning care done including shampoo. ROM exercises done. Absorbent underpad changed 2x. Drank coffee and juice with help. No BM today. Martin Jones, HHA
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A and B
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A or B :
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Question 4 of 10

4. Question

One example of writing correctly is:

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
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7/15: Assisted with shave, foot soak. C/O earache + put drops in ears. Dana Byer, HHA
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Children under the age of 8 but not infants.
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Neither A or B
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A or B
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Question 5 of 10

5. Question

Things that you should NOT do to make sure that you treat records as legal documents are:

Level of consciousness, Orientation to time, place and person Height, Weight,
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Urinary drainage bag output, Temperature, Pulse, Respiration rate, Blood pressure,
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Blood glucose readings, Color of the skin, Warmth and characteristics of skin,
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Things that the patient or resident says, Things that the patient or resident communicates
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Behaviors, like anger and yelling
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Unspecific details, Abbreviations that aren't accepted
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Question 6 of 10

6. Question

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

Level of consciousness, Orientation to time, place and person, Height, Weight,
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Urinary drainage bag output, Temperature, Pulse, Respiration rate, Blood pressure,
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Blood glucose readings, Color of the skin, Warmth and characteristics of skin,
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Things that the patient or resident says, Things that the patient or resident communicates
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Behaviors, like anger and yelling
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All of the above
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Question 7 of 10

7. Question

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:

True
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False
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Question 8 of 10

8. Question

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

Baths, Showers, Oral care, Denture care, Foot care, Hair and nail care,
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Urinary catheter care, Back care, Turning and positioning, Meal intake,
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Fluid intake, Activities, like walking, Range of motion exercises if done,
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Fluid intake, Activities, like walking, Range of motion exercises if done,
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All of the Above
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Question 9 of 10

9. Question

Documentation in the medical records must be:

Complete
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Correct
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Done on time
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All of the above
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Question 10 of 10

10. Question

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

Level of consciousness, Orientation to time, place and person Height, Weight
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Urinary drainage bag output, Temperature, Pulse, Respiration rate, Blood pressure
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Blood glucose readings, Color of the skin, Warmth and characteristics of skin
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Things that the patient or resident says, Things that the patient or resident communicates
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Behaviors, like anger and yelling
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All of the above
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Correct

Incorrect

HHA Medication/Documentation Legal Aspects Exam

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