Health Records and Documentation: Legal, Objective, and Timely
What this domain tests
Purpose and legal status of records, objective documentation, error correction, confidentiality, and reporting.
Core rules and concepts
- Records are legal documents, used for care, communication, quality review, research, and legal evidence.
- Document factually, objectively, and in real time. Include date, time, full name, and signature.
- Write in ink; do not use pencil or correction fluid.
- Correct an error with a single line, write "error", add date/time and initials, then write the correct entry. Do not overwrite or erase.
- Late entries must be labelled as late, with the actual date and time of entry and the time of the event.
- Use only approved abbreviations. "U" for units can be misread; write "unit".
Worked example
A nurse writes "10 mg" but the order was "1 mg". Reasoning: draw one line through the error so it remains readable, write "error", initial and date it, then write "1 mg". Do not use white correction fluid, because it hides the original entry and looks like tampering.
Traps that cost marks
- Charting a care action before performing it.
- Writing subjective opinions such as "patient was rude" instead of describing behaviour.
- Signing for a colleague's care.
- Using vague terms such as "patient fine".