Medical Records and Charting Flashcards
6 cards from real CMT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Medical Records and Charting flashcards as text
The SBAR communication format is used primarily for:
Answer: Handoff and critical communication between healthcare providers
SBAR (Situation, Background, Assessment, Recommendation) is a structured communication framework for healthcare handoffs and urgent communications.
Which of the following is an approved abbreviation for 'every day' in medical documentation?
Answer: Daily
The word 'daily' is the approved term. 'QD' and 'q.d.' are on The Joint Commission's Do Not Use list due to confusion with 'QID' and 'QOD.'
When documenting a patient's refusal of treatment, the medical record should include:
Answer: The treatment refused, explanation of risks provided, and patient's stated reason
Documentation of refusal must include what was refused, that risks were explained, the patient's stated reason, and that the provider was notified.
Protected health information (PHI) in electronic records must be safeguarded by:
Answer: Using automatic logoff, encryption, and unique user IDs
HIPAA's Security Rule requires technical safeguards including automatic logoff, encryption, access controls, and unique user identification.
Incident reports in healthcare are used to:
Answer: Document unusual occurrences for risk management and quality improvement
Incident reports document unusual occurrences, near-misses, and adverse events for risk management analysis and quality improvement.
The minimum data set that should be documented for every patient encounter includes:
Answer: Patient identification, date/time, vital signs, assessment, interventions, and provider signature
Every patient encounter requires documentation of identification, date/time, clinical findings, care provided, and provider identification.