Canadian Health Information Management Association Practice Exam

Which of the following is a characteristic of effective healthcare documentation?

1. Incomplete and vague records.

2. Clear, concise, and accurate information.

3. Subjective opinions included.

4. Documentation not legible.

The correct answer is: Clear, concise, and accurate information.

Effective healthcare documentation is characterized by clear, concise, and accurate information because it plays a critical role in ensuring continuity of care, patient safety, and quality of healthcare services. When documentation is clear, it allows healthcare providers to quickly understand a patient's history, needs, and the treatments being provided. Conciseness ensures that only relevant information is included, making it easier for others to read and comprehend, while accuracy is vital to ensure that the details recorded reflect the true condition and treatment of the patient. This effective documentation supports healthcare team communication, reduces the risk of errors, and contributes to better patient outcomes.