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Documentation: Legal Principles of Good Charting
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Please select the best response for each question.
1: If a record entry is not made in a timely manner, it may be excluded from evidence:
True
False
2: It is a good idea to remove information from a medical record if it makes you look bad.
True
False
3: Accuracy in charting is an important step in getting credibility with a jury.
True
False
4: Late entries in records rarely look suspicious.
True
False
5: One reason to document accurately is to ensure the provider gets paid for what he does.
True
False
6: Incident reports should be prepared whenever an adverse event occurs.
True
False
7: When an incident report is prepared, it should be documented in the medical record and incorporated into the medical record by reference.
True
False
8: It is better to write "all parameters normal" than to record specific information about a patient's vital signs.
True
False
9: You should never make any notes for your own personal use.
True
False
10: Information in medical records may be freely given to any relative of the patient without fear of repercussions.
True
False
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