HAC Documentation & Reporting Flashcards

Which of the following best describes objective information in a patient report?

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.

Under HIPAA, a healthcare aide may share a patient's health information with:

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.

The SBAR communication tool stands for:

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.

How should a healthcare aide record the time in a 24-hour (military) clock format for 3:30 PM?

Answer: 1530

In 24-hour time, PM hours are calculated by adding 12 to the standard hour, so 3:30 PM becomes 1530.

Which statement about electronic health records (EHRs) is 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.

A patient tells a healthcare aide, 'I'm feeling dizzy.' How should this be documented?

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.