Question

Every entry on a medical record must include the time, date, and ________________ of the health care professional who made the entry.

a) Employee ID
b) Witness signature
c) Shift supervisor
d) Full name

Answer 1

In medical records, every entry must include the time, date, and the full name of the health care professional responsible for the entry.

Every entry on a medical record must include the time, date, and full name of the health care professional who made the entry. The correct answer to the question is option d) Full name. It is crucial for maintaining the integrity of the medical record. Each entry must be attributable to a specific individual responsible for the care of the patient, and including the full name provides clear accountability.

Answer 2

The correct information required in every entry on a medical record, besides time and date, is the full name of the health care professional who made the entry.

Step-by-step explanation:

Every entry on a medical record must include the time, date, and full name of the health care professional who made the entry. The correct answer to the question is d) Full name. Medical records are legal documents, and it's essential that each entry is attributable to a specific individual for accountability, quality control, and legal purposes. Including the full name on a medical record ensures that anyone reviewing the record knows who provided each piece of information or care, which can be crucial for patient safety, follow-up care, and in case any questions or issues arise concerning the patient's medical treatment.