The Best Defense is a Good Documentation Offense

~ Exam ~

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This test has 18 questions.

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1. From a legal standpoint, if you provide care and do not document it, then the care:

  a. was done

  b. was not done

  c. was done by yourself and a co-worker

  d. was only half done


2. All of the following basic information should be included when you document in the medical record except:

  a. the date

  b. the time

  c. your name and title

  d. the day of the week


3. A key issue in many malpractice cases is:

  a. documenting too much information

  b. only documenting once in 24 hours

  c. failure to document

  d. easing errors


4. All of the following statements are true except:

  a. Document incident reports in the medical record.

  b. Do not use white out if you make a mistake.

  c. Reasons care was not given should be documented.

  d. Documenting ahead of time is not allowed.


5. If you forgot to put a check mark in the box on the flow sheet next to the words Breakfast Given, then legally
  a. The patient was not given breakfast.

  b. The patient only ate 50% of his breakfast.

  c. The patient received breakfast but ate nothing.

  d. The patient refused breakfast.


6. On your way home from work, you remembered that you forgot to document something. You should:

  a. forget about documenting it since you have finished work for the day.

  b. go back and write what you fogot in the margin of the page where you already documented.

  c. document it tomorrow using the notation "late entry" along with the date and time you are writing it.

  d. call your place of employment and ask someone else to document it for you since you aren't there to do it yourself.


7. Any education or instructions given to a client or the family of a client should be documented in the medical record.

  a. True

  b. False


8. Falsifying information in the medical record is not a criminal offense.

  a. True

  b. False


9. Once a client has a discharge order, we do not have to document any instructions we give them about what they are to do once they are at home.

  a. True

  b. False


10. It is okay to share your computer password with somebody else.

  a. True

  b. False


11. When a nurse takes a verbal order over the phone she should document that she read the order back to the doctor to check that she heard it correctly.

  a. True

  b. False


12. To save time when she is extremely busy, a nursing assistant should be encouraged to document care on everyone before she provides care to anyone.

  a. True

  b. False


13. You should write your name so that anyone can easily understand your signature when they see it in the medical record.

  a. True

  b. False


14. When a client refuses care, you don't have to document anything because you did not give any care.

  a. True

  b. False


15. In the future the use of a standardized medical record form and a national standard for charting would help because a person would not have to learn a new system of documentation wherever they changed jobs.

  a. True

  b. False


16. Writing "confidential" on the fax cover sheet, which is placed over the medical record you are getting ready to fax is not recommended.

  a. True

  b. False


17. After drawing a single line through a mistake in your documentation and signing your name and title, you should also write “error” next to the mistake.

  a. True

  b. False


18. Sharing your computer password is not permitted even when it saves valuable nursing time that can then be spent giving direct patient care.

  a. True

  b. False