Relias Training: Basics of Effective Documentation

What does the "D" in DAP note stand for?

DATA

Which of the following is the MOST accurate statement regarding documentation?

Documentation is the only way to prove what happened.

True or False: It is acceptable to go back into the medical record and REMOVE mistakes in a previously submitted note.

FALSE

Which of the following is an example of objective information?

Ken was able to recall five of seven items correctly.

Collaborative documentation is when the:

Service provider and the client document together.

Which of the following is an example of subjective information?

Sophie looked like she hadn't slept in a week.

What does the Golden Thread mean with regard to documentation?

That the assessment, treatment plan, and progress notes should all be connected

Which of the following pieces of information must be included in the documentation for medical necessity?

The client's diagnosis

When working with one person, when should another person's identifying information such as their name be included in the chart?

The other person's information should never be included

Which is the best example of how to document if you suspect a person was under the influence of alcohol when you saw them?

There was a strong smell of alcohol and six empty bottles on the table.

The provider documented: "Stevie was a drag today. He was rude and must have been tired." What type of information is this provider using in their documentation?

Unprofessional language