Documentation & Record Keeping Flashcards
7 cards from real CHT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation & Record Keeping flashcards as text
Which document serves as the primary legal record of a hyperbaric treatment session?
Answer: The patient treatment record/chart
The patient treatment record is the primary legal document capturing all clinical decisions, vital signs, and treatment parameters for each session.
When documenting a patient's response to treatment, the CHT should record vital signs at which intervals during a standard 90-minute dive at 2.4 ATA?
Answer: Every 30 minutes and whenever a clinical change occurs
Vital signs are typically recorded every 30 minutes and any time a clinically significant change is observed during the treatment session.
A patient refuses to sign the informed consent form before their first hyperbaric treatment. What should the CHT document?
Answer: Document the refusal, notify the supervising physician, and do not treat without consent
Informed consent is a legal and ethical requirement; a refusal must be documented and escalated to the physician before any treatment proceeds.
Which of the following must be documented in the chamber log after every treatment session?
Answer: Start/end times, maximum pressure, oxygen percentages, and any equipment anomalies
Chamber logs must include treatment times, pressure parameters, oxygen data, and any equipment issues to ensure traceability and regulatory compliance.
Under HIPAA regulations, hyperbaric treatment records must be retained for a minimum of how many years for adult patients?
Answer: 6 years
HIPAA requires covered entities to retain medical records and related documentation for a minimum of 6 years from the date of creation or last effective date.
A CHT notices a transcription error in yesterday's treatment record. The correct action is to:
Answer: Draw a single line through the error, write the correction, date, and initial it
The legally accepted method for correcting medical record errors is a single line through the mistake with the correction, date, and initials visible.
When an adverse event occurs during hyperbaric treatment, which documentation should be completed?
Answer: Both the treatment record and a separate incident/occurrence report
Adverse events require documentation in the treatment record AND a separate incident report to support quality improvement and risk management processes.