Documentation

What is a chart used for in healthcare systems?

• A chart is a legal record used to meet many demands of healthcare systems.

• A chart is used only for billing purposes in healthcare systems.

• A chart is a decorative item in healthcare offices.

• A chart is a tool for marketing healthcare services.

Which of the following is NOT a use of a chart in healthcare systems?

• A) Accreditation

• B) Medical insurance

• C) Legal Systems

• D) Cooking recipes

Fill in the blank: Charts in healthcare are used for _________.

• Accreditation, Medical insurance, Legal Systems

• Decorative purposes only

• Entertainment of patients

• Cafeteria menu planning

• Staff uniform selection

Charting is the process of adding ______ information to the chart.

• written

• numerical

• graphical

• verbal

Charting is also known as ______ or documenting.

• recording

• analyzing

• calculating

• measuring

What does documentation in healthcare involve?

• Recording the interventions carried out to meet patient’s needs

• Prescribing medication

• Scheduling appointments

• Diagnosing illnesses

Which of the following is important to document in patient care?

• The type of intervention

• The time care was given

• Signature of the person providing care

• All of the above

Fill in the blank: In the past, documentation was _______.

• written

• digital

• spoken

• animated

Today, a majority of facilities use ________ Health Record (EHR), also referred to as Electronic Medical Record (EMR).

• Electronic

• Paper

• Analog

• Manual

Which of the following statements is true?

• Documentation is no longer necessary in healthcare

• Most facilities still use only written documentation

• Most facilities now use Electronic Health Records (EHR)

• Documentation only includes the patient’s name