Legal & EthicalQuestion 169 of 200
Why is the documentation principle 'not documented = not done' important?
a.Because supervisors enjoy reading charts
b.Because residents demand it
c.Because documentation is optional
d.Because the legal medical record is the primary evidence of the care provided; if a treatment is not documented, courts, surveyors, and Medicare may treat it as if it never occurred
Explanation
Under 42 CFR §483.70(i) and Title 22 CCR §72543, facilities must maintain complete, accurate, accessible records on each resident. The medical record is a legal document. If care is not documented (or is documented late, falsely, or vaguely), it cannot be defended in court, audits, or surveys — and the facility/CNA may face citations, civil liability, and disciplinary action. CNAs must chart promptly, factually, in the resident's own words when quoted, and never document a task before performing it. Late entries are made as 'late entry' with current date/time.
Law Reference: 42 CFR §483.70(i); Title 22 CCR §72543Practice all 200 questions free — no signup required.
Related questions on this topic
- Which of the following is OUTSIDE a California CNA's scope of practice?
- A nurse asks a CNA to start an IV on a new admission because the unit is short-staffed. The CNA should:
- Under HIPAA's 'minimum necessary' standard (45 CFR §164.502(b)), a CNA should access protected health information (PHI):
- Under HIPAA 45 CFR §164.512, a CNA may disclose PHI WITHOUT the resident's written authorization in which situation?
- A resident asks the CNA for a copy of her own medical record. The correct CNA response is:
- A CNA posts a TikTok video taken in the nursing facility hallway. Two residents appear in the background, identifiable by face. This is:
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