Question

23 Explain documentation and describe ed terms and forms 12. Describe incident reporting and recording Multiple Choice ole Choice e large amount of time that a nursing as. . An incident is tant spends with residents will allow her A) An accident or unexpected event in the course of care Diagnose illnesses Deterrmine treatments Notice things about residents that other are team members may not notice ive medical advice (B) Any interaction between residents and staff (C) A normal part of facility routines (D) Any event in a resident's day Which of the following would be considered an incident? (A) A resident complains of a headache (B) A resident falls but is okay after the fall. (C) A resident wants to watch TV in the 2. h of the following statements is true of dent's medical chart? medical chart is the legal record of a ident's care all care needs to be documented. umentation can be put off until the day if a nursing assistant is busy ical charts are not considered legal ments. common living area. (D) A resident needs to be transferred from his bed to a chair Incidents should be reported to (A) The resident's family (B) The charge nurse (C) All staff on duty at the time of the 3. ould care be documented e care is given diately after care is given end of the day ver there is time incident (D) The doctor on call True or False 4.Documentation of incidents helps protect the resident, the employer and individual staff members. owing times to military time: The information in an incident report 6. If an NA does not actually see an incident but arrives after it has already occurred, she should document what she thinks happened. ing times to regular time: 7. The documentation of an incident should include who the nursing as- sistant thinks could be responsible for the incident. 8. Incident reports should be factual. 9. If a resident who is supposed to eat a 3 low-sodium meal eats a regular, unre- stricted meal, an incident report does not need to be completed 10.If an NA receives an injury on the job, he should file an incident report

Answer 1

1

.A. An incident is the accident or unexpected event during the course of care.

2

B.A resident falls but is okay after the fall  

( staff should report even minor incidents and near misses which are just as important as major events)

3.

A .the residents family.

(incidents should report to incharge nurse, an on-call doctor and co-staff to improve the quality. there is a chance to neglect in reporting to the family.

4. true. in case of any insurance or court actions, incident reporting is both beneficial for resident and hospital staff

5.true -even though it is confidential, it can be used in study purpose to provide quality of care,

6.false- incident should be reported by the respective staff to authority through particular form .and the data should be objective.

7.true

8.true( the report should be filled out as soon as possible so that the details would be accurate)

9.true

10.true.( in most cases accidents with patients are reported in incident reports. but in some facilities, injury to staff or visitor will also be included)