PSW: CHARTING AND
DOCUMENTATION EXAM WITH
QUESTIONS AND 100% CORRECT
SOLUTIONS 2025 UPDATE.
As a PSW it is important to remember that the residents chart is a _________ __________ and
information contained in the chart is confidential. - ANS legal document
A common rule in heath care is "if its not ____________(1), then it was not _________(2). -
ANS 1. charted
2. done
It is important to be objective and to chart only the ___________(1); don't document your
____________(2). - ANS 1. facts
2. opinions
What type of ink pen should be used for charting medical records? - ANS Black or blue ballpoint
pen
If a PSW makes a mistake should they use correction fluid (White-Out) to correct it? - ANS No
- don't use any correction fluids
- draw a line through the entry and write "error" and then initial it
What is the purpose of charting? - ANS - communicate with other members of the health care
team; physicians orders, care plan, progress notes
- documents the delivery of care
- documents and provides evidence to agencies that care has been provided
- to document for insurance purposes and/or legal actions
Who fills out the Care Plan? - ANS RN or RPN
It is important to use ________ _________ when describing an emotional statement made by a
resident. - ANS direct quotes
Would it be acceptable for a PSW to chart a procedure before it has been done? - ANS No!
How do you sign the chart once you are done writing your observations and the procedures you
have performed? - ANS First initial, last name, and job title
Is delirium a part of normal aging? - ANS No, never.
- the onset may vary depending on the severity of the cause and the resident's health status
DOCUMENTATION EXAM WITH
QUESTIONS AND 100% CORRECT
SOLUTIONS 2025 UPDATE.
As a PSW it is important to remember that the residents chart is a _________ __________ and
information contained in the chart is confidential. - ANS legal document
A common rule in heath care is "if its not ____________(1), then it was not _________(2). -
ANS 1. charted
2. done
It is important to be objective and to chart only the ___________(1); don't document your
____________(2). - ANS 1. facts
2. opinions
What type of ink pen should be used for charting medical records? - ANS Black or blue ballpoint
pen
If a PSW makes a mistake should they use correction fluid (White-Out) to correct it? - ANS No
- don't use any correction fluids
- draw a line through the entry and write "error" and then initial it
What is the purpose of charting? - ANS - communicate with other members of the health care
team; physicians orders, care plan, progress notes
- documents the delivery of care
- documents and provides evidence to agencies that care has been provided
- to document for insurance purposes and/or legal actions
Who fills out the Care Plan? - ANS RN or RPN
It is important to use ________ _________ when describing an emotional statement made by a
resident. - ANS direct quotes
Would it be acceptable for a PSW to chart a procedure before it has been done? - ANS No!
How do you sign the chart once you are done writing your observations and the procedures you
have performed? - ANS First initial, last name, and job title
Is delirium a part of normal aging? - ANS No, never.
- the onset may vary depending on the severity of the cause and the resident's health status
