Rules of charting - Never write inflammatory statements or argue on charts, do not leave blank lines between test, if you make a mistake mark it out with straight line, if you must add information write a separate addendum and sign and date, for computer charting do not copy and past someone else's note, always sign your note AND print your name, always leave room below your note for your notes to be amended and co-signed by attending/resident, medical student's note should always be more detailed than resident because of less clinical judgement and experience If you do not understand a question that is posed by a surveyor, what should you do? A. Explain that you are not allowed to answer any questions B. Answer the question to the best of your ability C. Tell the surveyor that you do not know the answer D. Ask the surveyor to restate or rephrase the question. - C. Tell the surveyor that you do not know the answer What action should you take if a deficiency is found during a survey of a health care agency where you work? A. seek a new job with a different agency within 60 days B. Ask if your responses to surveyor's questions created a problem C. Give honest information about the deficiency to patients/ residents D. Follow instructions from the team leader to correct the deficiency - D. Follow instructions from the team leader to

 

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