Corrent answers in green.
Incorrect answers in red.
1) The principle that without accurate documentation, a patient intervention cannot be said to have occurred, may be restated as:
  • Document everything you see.
  • If it wasn’t documented, it wasn’t done.
  • Document everything even before it happens.
  • Always sign every note that you write.
2) When documenting patient care, a health care professional should
  • use his or her professional judgment to determine what is important.
  • include every detail seen during patient care.
  • consider everything important.
  • include everything said during patient care verbatim.
3) The primary reason that documentation is important is
  • to avoid liability for medical errors.
  • to evaluate the health care professional’s performance.
  • to provide the patient with a record of his or her care.
  • to ensure good patient care.
4) Within a legal context, a court is more likely to believe
  • the health care professional’s oral testimony of what happened.
  • that the proper procedure was followed.
  • a patient’s testimony of what happened.
  • the written medical record of what happened.
5) When a health care professional documents information in a patient’s medical record, the health care professional
  • should indicate if a late entry was made.
  • must document the information as it happens.
  • may document information before it happens.
  • may document procedures performed by another health care professional.
6) When a health care professional documents what a patient says, the health care professional
  • may paraphrase in shorter form what the patient said for efficiency.
  • is expected to write down everything that was said verbatim.
  • should make a good faith effort to record important information verbatim.
  • should follow the adage: if it wasn’t recorded, it wasn’t said.
7) A health care professional must be objective when documenting a patient’s medical record, which means
  • avoiding judgmental comments.
  • not using your professional judgment regarding what is important to document.
  • a health care professional must make value judgments about a patient’s care.
  • a health care professional must sign his or her entries in the patient’s medical record.
8) If a health care professional makes a mistaken entry in a patient’s medical record, the health care professional should
  • correct it so long as the mistake is corrected on the same day it was written.
  • follow the health institution’s policies regarding corrections.
  • delete or cover the erroneous entry, then enter the correct information.
  • use his or her judgment on what to do based on a case-by-case basis.
9) Which of the following rules correctly states what you should NOT do when documenting a patient’s medical record?
  • Don’t make a late entry.
  • Don’t document for someone else.
  • Don’t use your judgment, document everything.
  • Don’t use abbreviations.
10) Which of these health care professional notes is an example of good documentation:
  • “12:30, 12/25/2009. Patient C/O pain in the hip. RN notified. Jane Doe, CNA.”
  • “Patient found on the floor, bleeding noted, the patient seemed confused.”
  • “12/25/2009. The patient’s temperature was noted to be 103 degrees, and the patient was noted to be very diaphoretic. Jane Doe, CNA.”
  • 17:00, 12/25/2009. Bleeding noted from surgical incision site on left hip. Vital signs were taken, within normal limits, and recorded. The patient, when asked, had no complaints. John Doe, RN, notified of bleeding at 17:10. Jane Doe, CNA.”
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