WorksheetsHealth Records Documentation
Total questions: 8
Worksheet time: 4mins
What is the purpose of Clinical Documentation?
Communication between members of the care team
To support planning for human resources
To document rationale and clinical reasoning
All of the above
Health records are commonly organized in what way?
The history is always at the beginning
The consent form is always at the beginning
The subjective assessment is always at the beginning
Each facility has its own unique approach, and it is your responsibility to be oriented
Each facility or organization has policies related to health records
True
False
What are three guidelines should always apply to entries in health records?
Be accurate, be clear, be subjective.
Be dated, be handwritten, be concise.
Be accurate, be concise, be clear.
Be signed, be chronological, be exaggerated.
Patients can share their own personal health record with their PT if they choose to.
True
False
How should errors be corrected in a handwritten health record?
White out the error, and write over it.
Draw a single line through the error, and initial it.
Block out the error fully so it cannot be read.
None of the above.
The Saskatchewan College of Physical Therapists regulates the protection of personal health information.
True
False
What should be included in the Objective section of a SOAP note?
Observation
Problem list
Discharge plan
Signs and symptoms
