Documentation Test

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1. A client's care plan is often developed by:
A home health aideDischarge plannerA nurseThe client's family

6. All entries in the chart must be signed with your first initial, last name, and your title.

2. Entries in a client's chart should be
Based on what you observeMeasure and hear what the client tells youBased on your best guess as to what the client feltWritten in felt penWritten in pencil

7. How much space should you leave between entries when you are writing a description of the care provided?
One lineTwo linesNo space at allA full page

3. Which of the following statements is subjective?
The client gained six poundsThe client ambulates without assistanceThe client said she was nauseatedThe client cannot state his or her name

8. Every home health agency uses the same forms for documenting care provided.

4. When is it okay to use correction fluid on a client's record?
When you make any mistakeWhen you just get one number wrongNeverWhen you get the date or time wrong

9. Only approved abbreviations may be used in chart entries.

5. It is okay to erase errors in a client's chart.

10. The client chart is a legal document.

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