22 Useful Free CNA Practice Exam Questions and Answers on Observation, Reporting and Documentation

Beside supporting patients with the routine care such as feeding, bathing, hygiene, grooming,… nursing assistant also take the responsibility for observation, reporting and documentation during the nursing process. To be a great NA, you must master these skills and do them with the fastest speed. With the aim of assisting nursing students to prepare for their CNA exams and helping nursing assistant to do their job better, 22 Useful Free CNA Practice Exam Questions and Answers on Observation, Reporting and Documentation offer a checklist of multiple choice questions and instant answers which focus on the process of reporting and documenting the patients’ information in the medical facilities. With the well-designed format, these free CNA test questions impress learners with its accessibility and a thorough coverage of core issues including care plan conference,charting,evaluation,oral report and so on. Plus, this quiz also equip learners with an overview of computerized medical record which is very essential for temporary nursing process. Till now, we seem to tell much about the benefits of this test! If you are still having any doubts or not believe what we present above, alright, please take a try now to experience!

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22 Useful Free CNA Practice Exam Questions and Answers on Observation, Reporting and Documentation

nursing process

• Systematic problem-solving method by which nurses individualize care for each client. The five steps of the nursing process are assessment, diagnosis, planning, implementation, and evaluation.
• A specific statement of what you want to achieve, giving direction to your plan of action
• A systemic, dynamic process by which the nurse, through interaction with the client, significant others, & health care providers, collects & analyzes data about the client.
• Information obtained through the senses

nurse's notes

• A piece of written, printed, or electronic matter that provides info or evidence that serves as an official record.
• report of patient progress and care provided by the staff member reporting it. This report is given verbally.
• Information obtained through the senses
• Record of the patient's care throughout the day; includes vital signs, treatment specifics, patient's response to treatment, and patient's condition

personal digital assistant (PDA)

• The process of making an entry on a patient's medical records.
• A piece of written, printed, or electronic matter that provides info or evidence that serves as an official record.
• Mobile device bigger than a phone but smaller than a laptop. Probably has a keyboard or at least a stylus (pen) and a touch-screen.
• A card-filling system that allows quick reference to a patient's care plan.

nursing diagnosis

• Using facts , not personal feelings or prejudices to describe things.
• A meeting of the members of the interdisciplinary team who ae directly involved in the care of the patient
• A specific statement of what you want to achieve, giving direction to your plan of action
• A clinical judgement about individual, family, or community responses to actual and potential health problems or life process (treatable by nurse)

kardex

• Using facts , not personal feelings or prejudices to describe things.
• The process of making an entry on a patient's medical records.
• A card-filling system that allows quick reference to a patient's care plan.
• Carrying out the plan of care

HIPAA- Health Insurance Portability and Accountability Act

• Using facts , not personal feelings or prejudices to describe things.
• The process of making an entry on a patient's medical records.
• Which act incorporates mandates to protect patient information and set national standards that address confidentiality, privacy and security
• Written documents that detail the expected course of treatment and expected outcomes for a DRG

planning

• A specific statement of what you want to achieve, giving direction to your plan of action
• A process that includes defining goals, establishing strategy, and developing plans to coordinate activities
• Documents on which frequent observations or specific measurements are recorded.
• The process of making an entry on a patient's medical records.

document

• A meeting of the members of the interdisciplinary team who ae directly involved in the care of the patient
• report of patient progress and care provided by the staff member reporting it. This report is given verbally.
• Using facts , not personal feelings or prejudices to describe things.
• A piece of written, printed, or electronic matter that provides info or evidence that serves as an official record.

Assessment

• Information obtained through the senses
• Systematic problem-solving method by which nurses individualize care for each client. The five steps of the nursing process are assessment, diagnosis, planning, implementation, and evaluation.
• A systemic, dynamic process by which the nurse, through interaction with the client, significant others, & health care providers, collects & analyzes data about the client.
• A specific statement of what you want to achieve, giving direction to your plan of action

critical (clinical) pathways

• Written documents that detail the expected course of treatment and expected outcomes for a DRG
• A card-filling system that allows quick reference to a patient's care plan.
• Documents on which frequent observations or specific measurements are recorded.
• The process of making an entry on a patient's medical records.

care plan conference

• A meeting of the members of the interdisciplinary team who ae directly involved in the care of the patient
• A piece of written, printed, or electronic matter that provides info or evidence that serves as an official record.
• A specific statement of what you want to achieve, giving direction to your plan of action
• The process of making an entry on a patient's medical records.
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