• Nobility Reigns Documentation - Employee Exam

    Complete the exam and certification form for the Documentation training.

  • Training Time: 1 Hour

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Instructions: Please read each question carefully and select the best answer from the options provided.

  • 1. Why is documentation considered a critical responsibility at Nobility Reigns?*
  • 2. Which software system does Nobility Reigns use for client documentation?*
  • 3. If an activity is not documented, how is it viewed legally?*
  • 4. How many activities must be offered and documented on first shift?*
  • 5. How many total activities must be documented per day between first and second shift?*
  • 6. How should third shift activity documentation be handled?*
  • 7. Which of the following is an appropriate example of professional documentation language?*
  • 8. Why are grammar, spelling, and punctuation critical in documentation?*
  • 9. Which word choice is most appropriate for professional documentation?*
  • 10. Instead of describing a client as “loud,” which wording is most appropriate?*
  • 11. What information must always be included in a progress note?*
  • 12. When documenting meals, staff should record:*
  • 13. A client completes a task entirely on their own without prompting. Should be documented as?*
  • 14. Client puts on their pants independently but needs help buttoning them. Should be documented as?*
  • 15. Staff complete 50% or more of a task for a client. This is documented as:*
  • 16. A client refuses to brush their teeth after being asked. How should this be documented?*
  • 17. What does verbal prompting mean?*
  • 18. Why is behavior documentation especially important?*
  • 19. Who may review documentation completed by staff?*
  • 20. Which statement best reflects Nobility Reigns’ documentation philosophy?*

  • Certificate of Completion: 

    This certificate acknowledges that the individual named below has successfully completed the Documentation Standards/Requirements training course provided by Nobility Reigns.

    This training provided comprehensive instruction on documentation expectations at Nobility Reigns, including the proper use of the CareSoft client documentation system and compliance with Wisconsin Department of Health Services (DHS) requirements. The course covered professional documentation standards, objective and respectful language usage, activity and calendar documentation, progress note completion, behavior tracking, meal and medication documentation, weights and vitals, incident reporting, and accurate skill-tracking using no assist, partial assist, full assist, verbal prompting, and declined classifications.

    Employees completing this course demonstrated an understanding of how documentation supports person-centered care, legal compliance, court and guardianship reviews, psychiatric and medical decision-making, and overall client safety. Emphasis was placed on grammar, spelling, punctuation, and professional word usage, as well as the importance of avoiding opinions, judgmental language, or authoritative phrasing in all client records.

    Successful completion of this training affirms the employee’s responsibility to document accurately, objectively, and consistently in accordance with Nobility Reigns policy and DHS regulations.

     

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Nobility Reigns Documentation | Form 0023

  • Should be Empty: