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Health Care Assistant (HCA) Practice Exam · Question

When documenting a client's vital signs, what should the HCA always include?

Accurate documentation includes the specific readings, date, time, and who took them, ensuring accountability and clear communication.

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Question: When documenting a client's vital signs, what should the HCA always include?

Answer options:

  • Only abnormal readings ✅ The date, time, and the HCA's initials
  • The client's entire medical history
  • Personal opinions about the client's personality

Correct answer: The date, time, and the HCA's initials

Explanation: Accurate documentation includes the specific readings, date, time, and who took them, ensuring accountability and clear communication.

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