PCT Documentation 3 — Questions and Answers
Question 1: What is the purpose of the 24-hour clock (military time) in medical documentation?
- To make records look more professional
- To eliminate AM/PM confusion and prevent timing errors (Correct answer)
- It is required by all state laws
- To synchronize with electronic health record systems only
Correct 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.
Question 2: A PCT forgets to document intake and output (I&O) for a two-hour period. What is the best course of action?
- Estimate the values and document them as if recorded on time
- Leave the section blank and say nothing
- Document the known information as a late entry, noting the delay (Correct answer)
- Ask a coworker to fill in the missing data
Correct 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.
Question 3: Which term describes documentation that is written in a structured, narrative paragraph form describing patient care events?
- Flowsheet charting
- Narrative charting (Correct answer)
- SOAP charting
- Focus charting
Correct answer: Narrative charting
Narrative charting uses a chronological paragraph format to describe patient care events and observations.
Question 4: A patient requests to see their own medical record. According to HIPAA, what is the patient's right?
- Patients have no right to their records
- Patients may request access to their records, which the facility must provide (Correct answer)
- Patients can only see records with physician approval
- Patients must wait 90 days before accessing records
Correct 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.
Question 5: Which of the following best describes 'charting by exception' (CBE)?
- Documenting only abnormal findings or deviations from the norm (Correct answer)
- Charting only exceptions to HIPAA rules
- Recording care only when the patient refuses treatment
- Skipping documentation when care is routine
Correct 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.
Question 6: When documenting a patient's fall, which information is most critical to include?
- The PCT's opinion about why the patient fell
- Time, location, patient condition before and after, and who was notified (Correct answer)
- Only that a fall occurred and that the patient was uninjured
- The names of any witnesses who saw the fall
Correct 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.
Question 7: What is 'informed consent' documentation used for?
- Recording that a patient was restrained
- Confirming a patient understands and agrees to a procedure or treatment (Correct answer)
- Documenting that a patient received pain medication
- Showing that a patient paid their bill
Correct 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.
PCT Documentation 3
What is the purpose of the 24-hour clock (military time) in medical documentation?