FFICM Documentation and Record Keeping 3

Question 1

Which of the following is a legal requirement when making an alteration to a handwritten ICU record?

Accepted Answer

Draw a single line through the error, initial, date, and time the correction

Answer

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?

Accepted Answer

Subject Access Request (SAR)

Answer

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?

Accepted Answer

A log recording who accessed or modified the record and when

Answer

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?

Accepted Answer

Flag clearly in the record that the patient has requested confidentiality restrictions

Answer

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?

Accepted Answer

It must be signed by the consultant, with clear reasoning and evidence of patient or proxy involvement

Answer

A DNAR order must be consultant-signed, clearly reasoned, and document involvement of the patient or, where they lack capacity, their family or proxy.

(FFICM) Final Faculty of Intensive Care Medicine Practice Test

(FFICM) Final Faculty of Intensive Care Medicine Practice Test

FFICM Documentation and Record Keeping 3