Documentation Flashcards
7 cards from real PCT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation flashcards as text
What is the purpose of the 24-hour clock (military time) in medical documentation?
Answer: To eliminate AM/PM confusion and prevent timing errors
Military time eliminates ambiguity between AM and PM, reducing the risk of medication and treatment timing errors.
A PCT forgets to document intake and output (I&O) for a two-hour period. What is the best course of action?
Answer: Document the known information as a late entry, noting the delay
A late entry is acceptable when clearly labeled as such; fabricating or guessing values is falsification of records.
Which term describes documentation that is written in a structured, narrative paragraph form describing patient care events?
Answer: Narrative charting
Narrative charting uses a chronological paragraph format to describe patient care events and observations.
A patient requests to see their own medical record. According to HIPAA, what is the patient's right?
Answer: Patients may request access to their records, which the facility must provide
HIPAA grants patients the right to access, inspect, and obtain copies of their medical records.
Which of the following best describes 'charting by exception' (CBE)?
Answer: Documenting only abnormal findings or deviations from the norm
CBE requires documentation only when findings are outside established norms, with normal findings assumed unless otherwise noted.
When documenting a patient's fall, which information is most critical to include?
Answer: Time, location, patient condition before and after, and who was notified
Comprehensive fall documentation must include the time, location, patient status, and notifications to support care continuity and incident review.
What is 'informed consent' documentation used for?
Answer: Confirming a patient understands and agrees to a procedure or treatment
Informed consent documents that a patient received information about a procedure and voluntarily agreed to it before care was provided.