mitc
19
qumc

What is the best method to follow when correcting an error in charting?
Make one line through the error, and then write the correct information.
Correct. The original information must remain visible.
Erase or white-out the error, and write in the correct information.
Incorrect. The original information must remain visible.
Scribble out the error so as not to confuse it with the correction.
Incorrect. The original information must remain visible.

Which of the following is a major purpose of medical documentation?
It helps ensure good patient care.
Correct. Good documentation helps the health care worker provide good patient care.
It prevents patients from suing.
Incorrect. The patient cannot be prevented from filing a lawsuit, but good documentation provides information to aid in the defense.
It keeps regulatory agencies from doing site visits.
Incorrect. Site visits are required by many regulatory agencies; good documentation ensures compliance.

Which of the following statements is accurate about good medical documentation?
In good medical documentation, the patient's name and identifying number are properly identified on every sheet.
Correct. Every single sheet of paper in the patient's medical record should have his or her name and identifying number.
Legible documentation is no longer an issue, because most facilities have computerized systems.
Incorrect. Even the most computerized health care facilities still have original handwritten documents that are included in the medical records.
The medical abbreviations in the text can be used at all health care facilities.
Incorrect. Only abbreviations listed in the official policy of the health care facility should be used.

When should a procedure/treatment be charted?
right after doing it
Correct. Always chart right after a procedure or treatment.
right before doing it
Incorrect. Always chart right after a procedure or treatment.
any time during your shift, as long as it is completed before leaving
Incorrect. Always chart right after a procedure or treatment.

