FFICM Documentation and Record Keeping 3 — Questions and Answers
Question 1: Which of the following is a legal requirement when making an alteration to a handwritten ICU record?
- Use correction fluid to conceal the original entry
- Draw a single line through the error, initial, date, and time the correction (Correct answer)
- Tear out and replace the page containing the error
- Write 'void' across the entire entry
Correct answer: Draw a single line through the error, initial, date, and time the correction
Alterations must preserve the original entry by drawing a single line through it, then signing, dating, and timing the correction.
Question 2: Under the GDPR and UK Data Protection Act 2018, patients have the right to access their medical records through which mechanism?
- Verbal request to any member of staff
- Subject Access Request (SAR) (Correct answer)
- Freedom of Information Act request
- Court order only
Correct answer: Subject Access Request (SAR)
Patients access their records by submitting a Subject Access Request, which must be fulfilled within one calendar month.
Question 3: What does the term 'audit trail' mean in the context of electronic ICU records?
- A summary of the patient's clinical progress
- A log recording who accessed or modified the record and when (Correct answer)
- A checklist verifying record completeness
- A financial record of treatment costs
Correct answer: A log recording who accessed or modified the record and when
An audit trail is an automatic log in electronic systems that records every access, view, or modification along with user identity and timestamp.
Question 4: A patient requests that certain information be withheld from family members. How should this be documented?
- Remove the information from the main record entirely
- Flag clearly in the record that the patient has requested confidentiality restrictions (Correct answer)
- Transfer care to another team to avoid conflict
- Inform the family regardless of the patient's wishes
Correct answer: Flag clearly in the record that the patient has requested confidentiality restrictions
The patient's confidentiality preference must be clearly documented so all staff are aware and can honour the request.
Question 5: Which of the following best describes a DNAR (Do Not Attempt Resuscitation) order documentation requirement?
- It requires only nursing staff signature
- It must be signed by the consultant, with clear reasoning and evidence of patient or proxy involvement (Correct answer)
- It is valid without any patient or family consultation
- It requires a court order to be enacted
Correct answer: It must be signed by the consultant, with clear reasoning and evidence of patient or proxy involvement
A DNAR order must be consultant-signed, clearly reasoned, and document involvement of the patient or, where they lack capacity, their family or proxy.
Question 6: During a malpractice claim, a clinician cannot locate an ICU chart entry they recall writing. What principle applies?
- Verbal testimony alone is sufficient to establish the event occurred
- If it is not documented, it is assumed not to have happened (Correct answer)
- Electronic backup always replaces missing paper records
- The burden of proof lies with the claimant to prove it did not happen
Correct answer: If it is not documented, it is assumed not to have happened
In medico-legal proceedings, the principle 'if it isn't written, it didn't happen' means undocumented care is assumed not to have been provided.
Question 7: Which of the following situations requires a formal capacity assessment to be documented in the ICU record?
- A patient refuses a blanket bath
- A patient refuses a life-sustaining intervention such as intubation (Correct answer)
- A patient asks for a second medical opinion
- A patient requests a vegetarian diet
Correct answer: A patient refuses a life-sustaining intervention such as intubation
Refusal of a life-sustaining treatment necessitates a formal, documented capacity assessment because of the gravity of the decision.
FFICM Documentation and Record Keeping 3
Which of the following is a legal requirement when making an alteration to a handwritten ICU record?