PCT Documentation 5

Question 1

In electronic health records (EHR), what is the purpose of an audit trail?

Accepted Answer

To record who accessed or modified a patient's record and when

Answer

An audit trail logs every access and modification to an EHR entry, supporting accountability and detecting unauthorized access.

Question 2

A PCT is documenting urine output. The patient produced 350 mL in 8 hours. How should this be recorded?

Accepted Answer

Record '350 mL' in the intake and output flowsheet

Answer

Urine output must be documented using precise metric measurements on the I&O flowsheet to support accurate clinical assessment.

Question 3

Which of the following is NOT appropriate to include in patient documentation?

Accepted Answer

Personal opinions about the patient's lifestyle

Answer

Personal opinions and judgments are inappropriate in medical records; documentation must be factual, objective, and professionally written.

Question 4

When documenting a wound assessment, which detail is most important to include?

Accepted Answer

Size, location, color, drainage, and surrounding skin condition

Answer

A complete wound assessment documents measurable and descriptive features that allow providers to track healing or detect complications over time.

Question 5

A PCT charts that a patient 'seemed upset' after a phone call. This phrasing is an example of what documentation problem?

Accepted Answer

Vague, subjective language that lacks specificity

Answer

'Seemed upset' is vague and interpretive; better documentation would describe observable behaviors such as 'patient was crying and refused to speak for 10 minutes.'

PCT Practice Test

PCT Practice Test

PCT Documentation 5