Reporting

Question 1

Define:

reporting

Answer 1

The verbal exchange of patient-related information among healthcare team members.

Reporting ensures continuity of care and patient safety.

Question 2

In which nursing process category do observing, reporting, and recording fall?

Answer 2

Implementation

Implementation involves executing care plans and includes monitoring patient responses and documenting care provided.

Question 3

Define:

urgent reporting

Answer 3

Reporting serious or unexpected changes in a patient’s condition.

Urgent reporting ensures timely medical intervention.

Question 4

Which situations require immediate reporting?

Answer 4

• Changes in vital signs
• Patient distress
• Falls
• Bleeding
• Aggressive behavior

Prompt reporting can prevent complications.

Question 5

Define:

routine reporting

Answer 5

Reporting daily care activities and patient conditions.

Routine reporting ensures continuity of care.

Question 6

List THREE examples of routine reporting.

Answer 6

1. Documenting vital signs.
2. Reporting food intake.
3. Noting daily activities.

Routine reporting keeps track of ongoing patient care.

Question 7

How often should routine reporting occur?

Answer 7

At the beginning and end of each shift, or when necessary.

Shift reports ensure all staff are updated on patient conditions.

Question 8

List TWO types of observations/data used in reporting.

Answer 8

1. Objective observations/data.
2. Subjective observations/data.

Objective observations are measurable, while subjective observations rely on patient reports.

Both types of observations contribute to comprehensive patient care.

Question 9

True or False:

Subjective data includes a patient saying they feel nauseous.

Answer 9

True

Subjective data is based on the patient’s self-reported symptoms.

Question 10

True or False:

It is acceptable to delay reporting a patient’s sudden change in condition.

Answer 10

False

Delaying reports can put the patient at risk.

Question 11

Define:

chain of command

Answer 11

The hierarchy of authority used to report issues and concerns.

Following the chain of command prevents miscommunication and ensures reports go to the correct authority.

Question 12

Who is the first person a CNA should report to in most cases?

Answer 12

The supervising nurse.

Nurses oversee patient care and escalate issues as needed.

Question 13

Define:

an incident report

Answer 13

A formal document describing an unexpected event or accident.

Incident reports help identify risks and prevent future occurrences.

Question 14

List THREE elements of an incident report.

Answer 14

1. Date and time.
2. Description of the event.
3. Actions taken.

Thorough reporting ensures accurate record-keeping.

Question 15

List THREE examples of incidents requiring reporting.

Answer 15

1. Patient falls.
2. Medication errors.
3. Equipment malfunctions.

Prompt reporting ensures appropriate follow-up.

Question 16

What should be included in a report about a patient’s fall?

Answer 16

• Date and time.
• Location of the fall.
• Patient’s condition.
• Any injuries.
• Actions taken.

Detailed reporting ensures proper follow-up and safety measures.

Question 17

True or False:

CNAs should wait until the end of their shift to report a patient’s severe pain.

Answer 17

False

Pain should be reported immediately for timely intervention.

Question 18

Fill in the blank:

An incomplete or missing report can result in _____ ______.

Answer 18

legal consequences

Proper documentation is a legal requirement.

Question 19

Fill in the blank:

Reports should be ______ and free from personal opinions.

Answer 19

objective

Sticking to facts ensures accurate documentation.

Question 20

Lis TWO common communication barriers in reporting.

Answer 20

1. Language differences.
2. Hearing impairment.

Overcoming barriers ensures effective communication.

Question 21

True or False:

CNAs should report any witnessed workplace safety violations.

Answer 21

True

Reporting violations helps maintain a safe work environment.

Question 22

Define:

ethical reporting

Answer 22

Reporting honestly and responsibly, following policies.

Ethical reporting maintains integrity in patient care.

Question 23

How should CNAs report a coworker’s negligence?

Answer 23

Notify the nurse in charge or supervisor.

Reporting negligence ensures patient safety.

Question 24

True or False:

CNAs can report concerns anonymously.

Answer 24

True

Some facilities allow anonymous reporting to protect whistleblowers.

Question 25

# Define: **patient rights** in reporting

Answer 25

The **right to file complaints** and have concerns addressed. ## Footnote Facilities must have grievance procedures in place.

Question 26

# Define: a **grievance** in healthcare

Answer 26

A **formal complaint** made by a patient or their family. ## Footnote Grievances must be addressed promptly to ensure patient satisfaction.

Question 27

What is the **role of an ombudsman** in healthcare reporting?

Answer 27

To **advocate for residents** and investigate complaints. ## Footnote Ombudsmen help resolve grievances in long-term care.

Question 28

What should a CNA do if a patient reports **mistreatment**?

Answer 28

Take it seriously and **report it immediately**. ## Footnote Patient safety is the top priority.

Question 29

List TWO key steps when taking a **telephone report**.

Answer 29

1. Identify yourself. 1. Write down details accurately. ## Footnote Clear documentation ensures proper follow-up.

Question 30

# Fill in the blank: When in doubt, \_\_\_\_\_\_.

Answer 30

report ## Footnote It is better to report potential issues than to miss important details.

Question 31

Why is **accurate documentation** important in healthcare?

Answer 31

* It provides a legal record of care. * It helps guide treatment. ## Footnote Documentation must be clear, factual, and timely.

Question 32

# True or False: CNAs should document care **before providing it**.

Answer 32

False ## Footnote Documentation should always be completed after care is given.

Question 33

# Fill in the blank: A CNA **should use** \_\_\_\_\_ **ink** when documenting patient care.

Answer 33

black or blue ## Footnote Using permanent ink ensures documentation is clear and valid.

Question 34

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

Answer 34

1. Draw a single line through it. 1. Write “error” above it. 1. Date and initial it. ## Footnote This method maintains the integrity of the medical record by documenting errors appropriately.

Question 35

Why must CNAs use **factual language** in documentation?

Answer 35

To **ensure clarity** and prevent misinterpretation. ## Footnote Opinions should not be included in medical records.

Question 36

# Fill in the blank: A CNA should **never alter** a patient’s \_\_\_\_\_\_ \_\_\_\_\_\_.

Answer 36

medical record ## Footnote Tampering with records is illegal and unethical.

Question 37

List TWO **key forms** used in patient charting.

Answer 37

1. Flow sheet 1. Nursing notes ## Footnote These forms track changes in patient condition and care provided.

Question 38

# Define: charting by exception

Answer 38

Documenting **only abnormal findings** rather than routine care. ## Footnote This method simplifies documentation while tracking important changes.

Question 39

# Define: workplace retaliation

Answer 39

**Punishment for reporting** misconduct or safety concerns. ## Footnote Retaliation is illegal and should be reported.