Certified Nursing Assistant (CNA) Prometric Practice Exam

What is a key responsibility of a nurse aide regarding resident documentation?

1. Altering records to reflect personal insights

2. Maintaining accurate and timely documentation of care provided

3. Documenting only unusual events

4. Recording information only upon request from superiors

The correct answer is: Maintaining accurate and timely documentation of care provided

Maintaining accurate and timely documentation of care provided is a fundamental responsibility of a nurse aide. This practice is crucial for several reasons. Accurate documentation ensures that the medical record reflects the care given to residents, which is essential for continuity of care among healthcare team members. Timely documentation helps in tracking changes in a resident's condition and informs necessary interventions by staff, thus enhancing patient safety. Moreover, comprehensive documentation protects both the patient and the healthcare providers, as it serves as a legal record of the care delivered. It also allows for proper communication among healthcare professionals, ensuring that all team members are on the same page regarding a resident's needs and treatment plan. In this context, the other options are not aligned with proper documentation practices. Altering records undermines integrity and goes against regulations. Documenting only unusual events fails to provide a complete picture of care, while recording information only upon request could lead to gaps in communication and inadequate care support.