Documentation & Health Records Flashcards

A nurse wrote the wrong vital sign value in a paper chart. What is the correct way to fix the entry?

Answer: Draw a single line through the error, write 'error' or 'mistaken entry,' initial and date it

A single line keeps the original entry readable, which preserves the legal integrity of the record.

Which abbreviation is on The Joint Commission's official 'Do Not Use' list?

Answer: QD

QD (daily) is easily confused with QID, so it must be written out as 'daily.'

In 24-hour (military) time, 7:45 PM is recorded as:

Answer: 1945

Add 12 to PM hours: 7 + 12 = 19, so 7:45 PM is 1945.

A patient's adult son calls the unit and asks for his mother's lab results. The patient has not authorized release. What should the HUC do?

Answer: Politely decline and refer the request according to facility privacy policy

Under HIPAA, PHI may only be disclosed to people the patient has authorized or as policy allows.

What does 'thinning' a patient's paper chart involve?

Answer: Removing older documents per facility policy and filing them so they stay part of the permanent record

Thinning moves older pages to a storage file but keeps them in the legal record; nothing is destroyed.

Which document lets a patient name someone to make healthcare decisions if the patient becomes unable to?

Answer: Durable power of attorney for health care

A durable power of attorney for health care (healthcare proxy) names a decision-maker.

Who owns the physical paper or electronic health record?

Answer: The healthcare facility

The facility owns the physical record, but the patient owns the information in it and has the right to access it.