CHT Documentation & Record Keeping 2 — Questions and Answers
Question 1: Which document serves as the primary legal record of a hyperbaric treatment session?
- The equipment maintenance log
- The patient treatment record/chart (Correct answer)
- The chamber operator daily checklist
- The facility incident report
Correct 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.
Question 2: 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?
- Once at the start and once at the end
- Every 30 minutes and whenever a clinical change occurs (Correct answer)
- Every 15 minutes throughout the dive
- Only if the patient reports symptoms
Correct 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.
Question 3: A patient refuses to sign the informed consent form before their first hyperbaric treatment. What should the CHT document?
- Proceed with treatment and note refusal afterward
- Document the refusal, notify the supervising physician, and do not treat without consent (Correct answer)
- Have a witness sign on the patient's behalf
- Obtain verbal consent and proceed
Correct 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.
Question 4: Which of the following must be documented in the chamber log after every treatment session?
- Patient diagnosis only
- Start/end times, maximum pressure, oxygen percentages, and any equipment anomalies (Correct answer)
- Only abnormal findings
- Staff names only
Correct 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.
Question 5: Under HIPAA regulations, hyperbaric treatment records must be retained for a minimum of how many years for adult patients?
- 3 years
- 5 years
- 6 years (Correct answer)
- 10 years
Correct 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.
Question 6: A CHT notices a transcription error in yesterday's treatment record. The correct action is to:
- Use correction fluid (white-out) to cover the error
- Draw a single line through the error, write the correction, date, and initial it (Correct answer)
- Shred the document and rewrite it
- Leave the error and attach a separate note
Correct 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.
Question 7: When an adverse event occurs during hyperbaric treatment, which documentation should be completed?
- Treatment record only
- Both the treatment record and a separate incident/occurrence report (Correct answer)
- An incident report only, filed separately from the chart
- A verbal report to the supervisor with no written documentation
Correct 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.
CHT Documentation & Record Keeping 2
Which document serves as the primary legal record of a hyperbaric treatment session?