Question

1. true or false: controlled substances require special storage and security by law.

○ true
○ false

1. which of the following actions is correct when documenting in the medical record?

○ only document what you observe and do, not what another caregiver tells you occurred.
○ record your opinion or personal comments when you believe it is appropriate
○ backdate the record if you realize you forgot to make an entry.
○ document long factual statements about the person you care for and include your personal comments

Explanation:

Question 9

Controlled substances (like certain medications, drugs) are regulated by law. Legal requirements mandate special storage (e.g., locked cabinets, restricted access) and security measures to prevent misuse, theft, or diversion. So the statement is true.

• For the first option: Medical record documentation should be based on direct observation and actions of the caregiver, not second - hand information from others. This is to ensure accuracy and accountability.
• The second option is wrong because medical records should be factual, not include personal opinions or comments.
• The third option is wrong as backdating medical records is unethical and often illegal, as it can compromise the integrity of the record.
• The fourth option is wrong because personal comments have no place in medical records; they should be objective and factual.

Answer:

TRUE

Question 10