TSS TSS Trauma Documentation & Legal Considerations Questions and Answers 2 — Questions and Answers
Question 1: Which document legally designates a person to make healthcare decisions for a trauma patient who is incapacitated?
- Durable power of attorney for healthcare (Correct answer)
- A living will only
- A DNR order
- A physician's order form
Correct answer: Durable power of attorney for healthcare
A durable power of attorney for healthcare legally authorizes a designated person to make medical decisions when the patient cannot.
Question 2: In trauma documentation, the term 'chain of custody' most directly refers to:
- The documented transfer of physical evidence from collection to analysis (Correct answer)
- The sequence of treatment providers caring for a patient
- The order in which trauma interventions are performed
- The documentation trail for medication administration
Correct answer: The documented transfer of physical evidence from collection to analysis
Chain of custody documents the handling of physical evidence to ensure its integrity and admissibility in legal proceedings.
Question 3: A trauma specialist is subpoenaed to testify about a patient's care. They should first:
- Consult with legal counsel and review the patient's medical records (Correct answer)
- Refuse to testify to protect patient confidentiality
- Testify from memory without reviewing records
- Share all patient records publicly before the hearing
Correct answer: Consult with legal counsel and review the patient's medical records
Consulting legal counsel and reviewing the medical record ensures accurate, legally sound testimony.
Question 4: The statute of limitations in a malpractice case involving trauma care refers to:
- The time period within which a lawsuit must be filed after the alleged injury (Correct answer)
- The maximum financial penalty for a malpractice verdict
- The number of witnesses allowed in a malpractice trial
- The duration of a specialist's professional license
Correct answer: The time period within which a lawsuit must be filed after the alleged injury
The statute of limitations sets the legal deadline for filing a malpractice lawsuit after an alleged injury occurs.
Question 5: When a trauma patient lacks capacity and no surrogate is available, the ethical and legal standard for decision-making is:
- The best interest standard, determining what a reasonable person would want (Correct answer)
- The clinician's personal judgment about optimal treatment
- Delaying all treatment until a surrogate is located
- Applying the most aggressive treatment available
Correct answer: The best interest standard, determining what a reasonable person would want
The best interest standard guides decision-making for incapacitated patients without surrogates by considering what a reasonable person would choose.
Question 6: An electronic health record (EHR) audit trail is important in trauma care because it:
- Records every access and modification to patient records, supporting accountability (Correct answer)
- Automatically corrects documentation errors
- Replaces the need for written consent forms
- Prevents unauthorized treatment decisions
Correct answer: Records every access and modification to patient records, supporting accountability
An EHR audit trail logs every access and change, creating accountability and a defensible legal record.
TSS TSS Trauma Documentation & Legal Considerations Questions and Answers 2
Which document legally designates a person to make healthcare decisions for a trauma patient who is incapacitated?