If an Item Was Not Charted in a Health Record,it

question 38

Multiple Choice

If an item was not charted in a health record,it is presumed that _____.

• A) If it wasn't documented,it wasn't done
• B) It was not necessary to document that item
• C) Providers can be excused for being too busy delivering care to document
• D) When an order is written,it was carried out even if not documented as such

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Definitions:

Appendix

A supplementary material at the end of a book, document, or report, containing additional information.

Supplementary Information

Supplementary information consists of additional details or data that support the main content but are provided separately to aid understanding.

Report Body

The main section of a report that contains the detailed information, analysis, and findings on the topic being reported.

Report Inclusion

The act of incorporating or integrating specific information, data, or findings into a formal report.