Documentation Flashcards
7 cards from real PCT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation flashcards as text
Which section of a SOAP note contains the patient's reported symptoms and complaints?
Answer: Subjective
The Subjective section records what the patient says about how they feel, including symptoms and complaints in their own words.
A PCT is transferring a patient to another unit. What documentation should accompany the patient?
Answer: A transfer summary including current status, pending orders, and care needs
A transfer summary ensures continuity of care by communicating current patient status, pending orders, and ongoing care needs to the receiving unit.
What is the legal significance of the phrase 'if it wasn't documented, it wasn't done'?
Answer: Undocumented care cannot be proven to have occurred in a legal or professional review
In healthcare, documentation serves as the legal record of care; without documentation, there is no verifiable proof that care was provided.
Which of the following is an appropriate way to document a patient refusal of care?
Answer: Document the refusal, what education was provided, and any potential risks explained to the patient
Documenting a refusal protects the patient's autonomy and demonstrates that the care team fulfilled their duty to inform the patient of risks.
What does the abbreviation 'NPO' mean in patient documentation?
Answer: Nothing by Mouth
NPO is a Latin abbreviation for 'nil per os,' meaning the patient should receive nothing by mouth, often used before surgery or procedures.
A PCT completes documentation and then realizes they documented in the wrong patient's chart. What should they do?
Answer: Notify a supervisor immediately and follow facility policy for correcting the error
Misdirected documentation is a serious error that must be corrected following facility protocols, as it can affect patient safety and treatment decisions.
Which of the following best describes the purpose of an Advance Directive in a patient's medical record?
Answer: It documents the patient's wishes for care if they become unable to make decisions
An Advance Directive (such as a living will or healthcare proxy) outlines the patient's preferences for medical treatment if they lose decision-making capacity.