Deck 21: Documentation

Question 1

All of the following are advantages of the EMR except:

A)lack of standardization among systems.
B)increased storage capacity.
C)information is concurrently available even at remote sites.
D)increased accuracy.

Answer 1

lack of standardization among systems.

Question 2

Which of the following methods of documentation is probably best for a clinician who is pressed for time?

A)SOAP
B)APIE
C)PIP
D)SBAR

Answer 2

PIP

Question 3

Which of the following outlines the professional standards for respiratory therapists (RTs)?
1)American Association for Respiratory Care (AARC) clinical practice guidelines
2)Respiratory care practice act and regulations
3)Place of employment
4)The Joint Commission

A)1, 2, and 4
B)1, 2, and 3
C)1, 2, 3, and 4
D)2 and 4

Answer 3

1, 2, 3, and 4

Question 4

The absence of information or the lack of documented recognition of specific problems could result in which one of the following situations?

A)Malpractice
B)Reduction in salary for an RT
C)Reduction in workload
D)Probation status for the clinician at fault

Question 5

According to experts, obtaining a good _____________ from a patient can give you a reasonable chance of correctly identifying a patient's problem before you do a single test.

A)arterial blood gas (ABG) results
B)chief complaint
C)medical history
D)appearance

Question 6

What does the letter I stand for in the APIE method of documentation?

A)Implementation
B)Impact
C)Inconsistencies
D)Initiative

Question 7

Which of the following organizations influences what needs to be documented in a patient's medical record?

A)The Joint Commission
B)Center for Medicare and Medicaid Services (CMS)
C)Financial intermediaries
D)All of the above

Question 8

The major purpose of the electronic medical record (EMR) includes which of the following?

A)Increase efficiencies in the healthcare system
B)Improve the quality of patient care
C)Increase patient safety
D)All of the above

Question 9

Which of the following charting methods has been promoted with implementation of rapid response teams (RRTs)?

A)PIP
B)SOAP
C)SBAR
D)APIE

Question 10

Which of the following definitions is consistent with negligence?

A)Failure to document a procedure performed on a patient
B)Failure to explain to a patient the purpose of a therapy
C)Failure to obtain a license to practice despite good clinical performance
D)Failure to use a reasonable amount of care that results in injury or damage to another

Question 11

Which of the following sections of the patient assessment or procedures should be charted immediately?

A)Date and time of test or treatment
B)Vital signs
C)Result of or response to treatment, including adverse reactions
D)Drugs and their dosages

Question 12

The patient's medical record is a/an:

A)financial document.
B)legal document.
C)educational tool.
D)all of the above.

Question 13

What is the primary goal of The Joint Commission?

A)Monitor financial reimbursement of hospitals
B)Review healthcare organizations to improve the quality of healthcare and patient safety
C)Provide healthcare workers with a safe work environment
D)Monitor the ethical practice of medicine at healthcare organizations

Question 14

Which of the following conditions is not required for the legal definition of negligence?

A)The defendant owed a duty of care to the plaintiff.
B)The defendant breached that duty.
C)The plaintiff suffered a legally recognizable injury.
D)The defendant's breach of duty of care did not cause the plaintiff's injury.

Question 15

All of the following are examples of "objective" data, except:

A)laboratory results.
B)observation of a patient's sleep apnea.
C)the patient's report of the amount of sputum that he or she produces daily.
D)the physician's interpretation of the patient's electrocardiogram (ECG).

Question 16

Which of the following words is not consistent with the definition of the SOAP charting method?

A)Subjective
B)Objective
C)Assessment
D)Physical examination

Question 17

Which of the following data do not constitute part of the objective information section in the SOAP charting method?

A)Vital signs
B)Review of systems
C)Review of clinical laboratory data
D)Review of pulmonary function test results