PCT Documentation 3

Question 1

What is the purpose of the 24-hour clock (military time) in medical documentation?

Accepted Answer

To eliminate AM/PM confusion and prevent timing errors

Answer

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?

Accepted Answer

Document the known information as a late entry, noting the delay

Answer

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?

Accepted Answer

Narrative charting

Answer

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?

Accepted Answer

Patients may request access to their records, which the facility must provide

Answer

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)?

Accepted Answer

Documenting only abnormal findings or deviations from the norm

Answer

CBE requires documentation only when findings are outside established norms, with normal findings assumed unless otherwise noted.

PCT Practice Test