Communication & CultureQuestion 24 of 200
Which of the following CNA documentation entries is most appropriate?
a.'Family is difficult.'
b.'Resident was rude today.'
c.'Resident is depressed and needs Prozac.'
d.'Resident ate 75% of breakfast; refused shower stating she wanted to rest; voided 200 mL clear yellow urine.'
Explanation
Per 42 CFR §483.20(g), documentation must be accurate, objective, factual, timely, and within scope of practice. Option b records measurable facts (intake %, refusal with stated reason, output amount and characteristics). Subjective judgments ('rude,' 'difficult'), diagnoses ('depressed'), and medication recommendations ('Prozac') are outside CNA scope and may misrepresent the resident. Objective documentation supports continuity of care and legal protection.
Law Reference: 42 CFR §483.20(g) (accurate documentation)Practice all 200 questions free — no signup required.
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