Deck 18: Record-Keeping and Documentation

Question 1

Records should be Clear, Intelligible and _______?

A) Accessible
B) Available
C) Annotated
D) Accurate

Answer 1

D

Question 2

The E in the No Elbow Rule stands for _______?

A) Erasing
B) Editing
C) Electronic
D) Entries

Answer 2

A

Question 3

When writing in patients' notes what must always be there?

A) Date, time, signature, printed name and position held and supervisor's signature
B) Date, time, ward, signature.
C) Date, time, signature, printed name and position held
D) Date, time, signature, printed name

Answer 3

C

Question 4

Which one of the following is a legal requirement to be complied with in relation to records?

A) Data Protection Act
B) Caldicot principles
C) NMC Record Keeping
D) Code of Professional Conduct

Question 5

If you make a mistake in a record how should it be corrected?

A) With correction fluid
B) Scribble it out
C) Put a single line through the record
D) Tell your supervisor

Question 6

What colour ink can be used when writing in patients records?

A) Any, as long as it is legible
B) Black
C) Black or dark blue
D) Black, blue, green and red

Question 7

What does contemporaneous mean?

A) Written in plain language
B) Comprehensively written
C) Written in real time.
D) Written in a chronological order

Question 8

Who adopts the approach that "if it is not recorded, it has not happened"?

A) The Nursing and Midwifery Council
B) Courts of Law
C) The Data Protection Act
D) The doctors

Question 9

Who can write in the patients' notes?

A) All relevant professionals and the patient
B) Medical and nursing staff
C) Medical, nursing and other health and social care professionals
D) Anyone

Question 10

Record keeping or rather, poor record keeping is the ----------- highest reason why registered nurses are removed from the professional register.

Question 11

The Nursing and Midwifery Council (NMC) (2015) state that nurses must 'keep clear and accurate - - - - - - relevant to your practice'.

Question 12

Records are usually kept for a minimum of ---- years for an adult over 21.

Question 13

There are three main legal aspects underpinning record keeping, these being: data protection, confidentiality and ----------------------------------------------------

Question 14

Patients can now request to see all of their medical records, they are no longer a secret. The ----------------------Act helped to bring this change about.

Question 15

A student nurse you must have each record you write in a patients notes countersigned by a qualified nurse until they are deemed as --------------------- in record keeping.

Question 16

The entry should have the time entered using a ----------------------- hour clock.

Question 17

The record should be written up as soon as possible after the episode of care and any temporary note taking, for example in an emergency situation, should be formalized within ------------------ hours.

Question 18

Clients / patients records must be kept safe and stored appropriately to maintain ----------------------------------

Question 19

TPR is an acceptable or unacceptable abbreviation

Question 20

Nurses often blame lack of ------------------- a reason for poor record keeping

Question 21

There is now a move towards -------------------- record keeping

Question 22

Record keeping is an integral part of care delivery and enhances -----------------between the health care team.

Question 23

The NMC ------ is the current published guidance for record keeping.

Question 24

The fundamental principle in relation to record keeping is that if it is not recorded it did not ------------------------