HAC HAC Documentation & Reporting 2 — Questions and Answers
Question 1: Which of the following best describes objective information in a patient report?
- 'The patient seems uncomfortable'
- 'The patient's skin felt warm, temperature was 101.2°F' (Correct answer)
- 'The patient looks like they are in pain'
- 'The patient appears anxious'
Correct answer: 'The patient's skin felt warm, temperature was 101.2°F'
Objective information is measurable and observable, such as a recorded temperature, rather than an interpretation or assumption.
Question 2: Under HIPAA, a healthcare aide may share a patient's health information with:
- A neighbor who asks about the patient's condition
- A coworker who is not involved in the patient's care, out of curiosity
- Members of the care team directly involved in the patient's treatment (Correct answer)
- Family members without the patient's permission in all situations
Correct answer: Members of the care team directly involved in the patient's treatment
HIPAA permits sharing protected health information only with those directly involved in the patient's care on a need-to-know basis.
Question 3: The SBAR communication tool stands for:
- Situation, Background, Assessment, Recommendation (Correct answer)
- Safety, Baseline, Action, Response
- Symptom, Behavior, Appearance, Review
- Status, Brief, Alert, Report
Correct answer: Situation, Background, Assessment, Recommendation
SBAR (Situation, Background, Assessment, Recommendation) is a structured communication framework used to convey patient information clearly and efficiently between care team members.
Question 4: How should a healthcare aide record the time in a 24-hour (military) clock format for 3:30 PM?
- 0330
- 1530 (Correct answer)
- 3300
- 1330
Correct answer: 1530
In 24-hour time, PM hours are calculated by adding 12 to the standard hour, so 3:30 PM becomes 1530.
Question 5: Which statement about electronic health records (EHRs) is correct?
- Aides should share their login credentials to save time
- Each user logs in with their own unique credentials to maintain accountability (Correct answer)
- EHR entries can be deleted if a mistake is made
- EHRs do not require the same accuracy as paper charts
Correct answer: Each user logs in with their own unique credentials to maintain accountability
Each staff member must use their own login so that all entries are traceable to the individual who made them, which is essential for legal and clinical accountability.
Question 6: A patient tells a healthcare aide, 'I'm feeling dizzy.' How should this be documented?
- 'Patient is dizzy.'
- 'Patient appears dizzy.'
- 'Patient states he is feeling dizzy.' (Correct answer)
- 'Patient seems like he might be dizzy.'
Correct answer: 'Patient states he is feeling dizzy.'
Quoting or paraphrasing what the patient said (e.g., 'patient states') accurately identifies the information as subjective and sourced directly from the patient.
HAC HAC Documentation & Reporting 2
Which of the following best describes objective information in a patient report?