FFICM Documentation and Record Keeping 2 — Questions and Answers
Question 1: Under UK law, what is the minimum retention period for adult inpatient medical records in NHS hospitals?
- 5 years from last episode
- 8 years from last episode (Correct answer)
- 10 years from last episode
- Indefinitely
Correct answer: 8 years from last episode
NHS records must be retained for 8 years from the last episode of care for adults under current NHS guidance.
Question 2: Which of the following best describes 'contemporaneous documentation' in critical care?
- Records written at the end of each nursing shift
- Records written at the time or as soon as practicable after an event (Correct answer)
- Records completed within 24 hours of an event
- Records reviewed and countersigned by a consultant daily
Correct answer: Records written at the time or as soon as practicable after an event
Contemporaneous documentation means recording events at the time they occur or as soon as reasonably possible afterward.
Question 3: A patient in the ICU lacks capacity. Who should be consulted regarding decisions documented in the medical record?
- The patient's GP only
- Next of kin as the legal decision-maker
- Those close to the patient and any legally appointed proxy decision-maker (Correct answer)
- The hospital ethics committee only
Correct answer: Those close to the patient and any legally appointed proxy decision-maker
Under the Mental Capacity Act, clinicians must consult those close to the patient and any legally appointed attorney or deputy when documenting best-interest decisions.
Question 4: When a medication error is discovered in the ICU, what is the correct documentation approach?
- Document only in the incident reporting system to avoid duplication
- Correct the error in the original record using correction fluid
- Document factually in the medical record and file a separate incident report (Correct answer)
- Omit from medical records to protect staff involved
Correct answer: Document factually in the medical record and file a separate incident report
Errors must be recorded factually in the patient's medical record and reported separately through the incident reporting system.
Question 5: Which component is MOST important to include when documenting a family meeting in critical care notes?
- Names and signatures of all family members present
- A verbatim transcript of all statements made
- Who was present, information given, understanding assessed, and agreed plan (Correct answer)
- Duration of the meeting in minutes
Correct answer: Who was present, information given, understanding assessed, and agreed plan
Family meeting documentation should capture attendees, information communicated, assessment of understanding, and the agreed care plan.
Question 6: What is the primary purpose of the ICU admission note?
- To summarise the patient's entire past medical history
- To establish a baseline clinical assessment and initial management plan (Correct answer)
- To list all medications the patient is currently prescribed
- To document the patient's next of kin contact details
Correct answer: To establish a baseline clinical assessment and initial management plan
The admission note establishes a baseline clinical picture and outlines the initial management plan to guide subsequent care.
Question 7: If an ICU doctor disagrees with an entry made by a colleague, what is the correct approach?
- Cross out the incorrect entry and rewrite it
- Add a dated, signed addendum documenting the differing clinical opinion (Correct answer)
- Remove the entry from the electronic record system
- File a formal complaint and leave the record unchanged
Correct answer: Add a dated, signed addendum documenting the differing clinical opinion
Disagreements should be recorded as a separate, dated and signed addendum rather than altering the original entry.
FFICM Documentation and Record Keeping 2
Under UK law, what is the minimum retention period for adult inpatient medical records in NHS hospitals?