Wisconsin CNA State Exam Vocabulary Practice

What term refers to a complete record of key clinical data and medical history, such as demographics, vital signs, diagnoses, medications, treatment plans, progress notes, problems, immunization dates, allergies, and test results?

1. Respiratory system

2. Resuscitation

3. Resident's chart

4. Restorative care

The correct answer is: Resident's chart

The term that describes a complete record of key clinical data and medical history is indeed the resident's chart. This document serves as a comprehensive compilation of all relevant information about a patient, including personal demographics, vital signs, and crucial medical details such as diagnoses, medications, treatment plans, and allergies. The resident's chart is essential for ensuring that all healthcare providers have access to consistent and accurate information, facilitating coordinated and informed care. The other terms listed do not refer to comprehensive medical records. The respiratory system pertains specifically to the organs and structures involved in breathing and gas exchange. Resuscitation refers to emergency procedures performed to restore breathing and circulation in individuals who are in cardiac arrest or not breathing. Restorative care is focused on helping patients regain or maintain their independence and best functional abilities following illness or injury, rather than documenting their medical history.