Module 06 — Documentation Standards

Knowledge Check

Answer all 5 questions. You need 80% (4 of 5) to pass. Your results are recorded.

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1.The Daily Visit Log must be completed:

Within one week of the visit The same day as the visit Before the end of the pay period Only if something unusual happened

2.You realize you made an error on yesterday's Visit Log. You should:

Use white-out to correct it Rewrite the entire log on a fresh form Draw a single line through the error, write the correction, initial and date it Ignore it — it's not a big deal

3."If you didn't document it..."

It's fine as long as you remember It didn't happen — legally speaking Your supervisor will document it for you You can add it later from memory

4.Falsifying documentation (visit logs, timesheets) is:

A minor policy violation Grounds for immediate termination and potentially federal fraud Only a problem if you get caught Acceptable if you forgot to document in real time

5.Your documentation should be:

Detailed with your personal opinions about the patient Factual, objective, complete, and timely As brief as possible to save time Written in medical terminology only

Documentation Standards

Knowledge Check

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Module Complete!