CHT Documentation & Record Keeping 3 — Questions and Answers
Question 1: Which regulatory body's standards most directly govern documentation requirements for hospital-based hyperbaric facilities in the United States?
- FDA
- The Joint Commission (TJC) (Correct answer)
- OSHA
- EPA
Correct answer: The Joint Commission (TJC)
The Joint Commission sets accreditation standards for hospital-based hyperbaric programs, including specific documentation and record-keeping requirements.
Question 2: What information must be documented before initiating oxygen therapy in the hyperbaric chamber?
- Patient's insurance information
- Pre-treatment assessment including contraindication screening and vital signs (Correct answer)
- Only the patient's name and date of birth
- Physician's home phone number
Correct answer: Pre-treatment assessment including contraindication screening and vital signs
A pre-treatment assessment documenting contraindication screening, current vital signs, and patient condition is mandatory before initiating HBO therapy.
Question 3: In a monoplace hyperbaric chamber, who is responsible for completing the treatment record documentation?
- The patient
- The referring physician
- The CHT or hyperbaric nurse operating the chamber (Correct answer)
- The billing department
Correct answer: The CHT or hyperbaric nurse operating the chamber
The certified hyperbaric technician or nurse operating the chamber is responsible for accurate and complete treatment record documentation.
Question 4: Which of the following is an example of objective data that should be documented in a hyperbaric treatment record?
- Patient states 'I feel better today'
- Blood pressure reading of 138/86 mmHg (Correct answer)
- Patient appears anxious
- Wound looks improved
Correct answer: Blood pressure reading of 138/86 mmHg
Objective data consists of measurable, quantifiable findings such as numerical vital sign values that can be verified by another observer.
Question 5: A patient's wound measurement documented during the previous visit shows the wound increased in size. How should the CHT handle this documentation?
- Omit the measurement to avoid alarming the patient
- Accurately document the measurement and alert the supervising physician (Correct answer)
- Estimate a smaller size to show improvement
- Repeat the measurement multiple times until a smaller number is obtained
Correct answer: Accurately document the measurement and alert the supervising physician
Accurate documentation is a legal and ethical obligation; any worsening clinical finding must be recorded and communicated to the supervising physician.
Question 6: Equipment calibration records for a hyperbaric chamber oxygen analyzer should be maintained for at least:
- 30 days
- 6 months
- The life of the equipment plus applicable regulatory retention period (Correct answer)
- 1 year only
Correct answer: The life of the equipment plus applicable regulatory retention period
Equipment calibration and maintenance records should be retained for the life of the equipment plus the facility's applicable regulatory retention period to demonstrate ongoing compliance.
Question 7: When a hyperbaric technician administers a treatment under a physician's verbal order, proper documentation requires:
- No additional documentation beyond the treatment record
- Recording the verbal order and obtaining a countersignature from the physician within the facility's required timeframe (Correct answer)
- Having another staff member co-sign as a witness to the verbal order
- Waiting until the physician can write the order before treating
Correct answer: Recording the verbal order and obtaining a countersignature from the physician within the facility's required timeframe
Verbal orders must be documented at the time given and countersigned by the ordering physician within the timeframe specified by facility policy.
CHT Documentation & Record Keeping 3
Which regulatory body's standards most directly govern documentation requirements for hospital-based hyperbaric facilities in the United States?