Deck 11: Documentation and Goals Assessment

Question 1

Where are the consents for surgery contained in the patient's chart?

A) Operative data
B) Progress notes
C) Physician orders
D) Multidisciplinary records

Answer 1

Operative data

Question 2

Which of the following is NOT found in the laboratory reports?

A) Computerized tomography reports
B) Arterial blood gas reports
C) Hematology reports
D) Endocrinology reports

Answer 2

Computerized tomography reports

Question 3

How are entries entered into the medical record?

A) In chronological order
B) In random order
C) In order of department
D) Alphabetical order

Answer 3

In chronological order

Question 4

Which part of the chart contains temperature,pulse,respiration,blood pressure,urine output,oral intake (fluids),and daily weights?

A) Physician's Orders
B) History and Physical Examination
C) Multidisciplinary Records
D) Graphic Record

Question 5

Which of the following represents falsification of the medical record?
I.Concealment of an incident
II.Making up ventilator settings
III.Charting an arterial blood gas that wasn't done

A) II only
B) I and II
C) III only
D) I, II, and III

Question 6

Vital signs,breath sounds,jugular venous distention,heart tones,SpO₂,and bowel sounds are all examples of _________________.

A) objective data.
B) subjective data.
C) clinical goals.
D) graphic records.

Question 7

Which of the following is NOT true about the patient's medical record?

A) It serves as legal proof of the nature of care, quality of care, and timeliness of care.
B) It is the only source on a given patient referred to by all health care professionals
C) The hospital may use it for risk management, reimbursement purposes, or research purposes among others.
D) Assessment(s), treatment(s), procedure(s), and test(s) are all recorded in it.

Question 8

How is the history of the patient obtained by the physician?

A) From the patient
B) From the physical examination
C) From the patient's family
D) a and c

Question 9

Which of the following is found in the discharge plan?
I.Any prescribed medication
II.Teaching for prescribed medication
III.Laboratory results

A) I and II
B) I only
C) II and III
D) I, II, and III

Question 10

Information provided to the physician by the patient is _______________________.

A) contained in the progress notes.
B) always confidential.
C) objective data.
D) subjective data

Question 11

Which of the following are NOT included in imaging reports?

A) Ultrasound
B) Surgery
C) Chest radiographs
D) Magnetic resonance imaging scans

Question 12

What are measurable,demonstrated outcomes that can be assessed following patient treatment or intervention?

A) Goals
B) Objectives
C) Assessments
D) Procedures

Question 13

How are medications recorded in the patient's chart?

A) In random order
B) In alphabetical order
C) Hourly
D) In chronological order

Question 14

Which part of the medical record states the date and time the patient was admitted to the acute care facility as well as the patient's medical diagnosis?

A) Physician's orders
B) Progress notes
C) Admission record
D) Medical history

Question 15

What is a compilation of pertinent facts of a patient's life and health history,illness(es),and treatment(s)written by health care professionals who have contributed to the care of that patient?

A) Risk management
B) The medical record
C) Clinical goals
D) Physician's orders

Question 16

What is the purpose of the medical record?

A) It is temporary proof of the nature of care, quality of care, and timeliness of care.
B) It is the one place where all pertinent medical information on a patient is recorded and accessible to all health care professionals caring for that patient.
C) It is an approximate record of the patient's condition, illness, and treatment.
D) To provide a written source of information regarding that patient providing a common source of information for all caregivers.

Question 17

Which of the following are recorded in the patient's record?
I.Tests
II.Treatments
III.Procedures
IV.Assessments

A) I and II only
B) II and III only
C) I, III, and IV
D) I, II, III, and IV

Question 18

Which of the following is NOT true concerning documentation?

A) Document things in anticipation of doing it
B) The date and time of interaction
C) Accuracy, timeliness, and truthfulness all are important
D) Document only what has been performed

Question 19

Legally,if an event is not documented in the patient's medical record,_______________.

A) it can be documented up to one week after the event.
B) it can be charged to the patient's hospital bill.
C) it was not done.
D) it is valid only if the patient remembers the event.

Question 20

Why are the medical record is used by third-party payers?

A) For patient information for future care
B) To assist physician's diagnose patients
C) For purposes of reimbursement
D) To provide patient's a copy of their chart

Question 21

When attempting to achieve ventilation goals the respiratory care practitioner should assess the ________________.

A) PaO₂.
B) SaO₂.
C) PaCO₂.
D) HCO₃.

Question 22

A patient with COPD who has oxygen and a nebulizer at home is ready to be discharged.The practitioner enters the patient's room to reinforce previous directions.The patient states he knows how to use the home care devices and how they are to be used.How should the practitioner proceed with the instructions?

Question 23

What are measurable outcomes the patient is expected to achieve following the intervention of a health care practitioner?

A) Clinical goals
B) Charting by exception
C) Objective data
D) Progress notes

Question 24

A patient was given a respiratory treatment by a practitioner who did not chart the treatment immediately on the patient's chart due to an excessive workload.Ultimately,the treatment was not charted on the medical record.What problem is associated with the therapist's judgement?

Question 25

What is the method of charting that usually employs fill-in-the-blank forms where only data that change are documented?

A) Clinical goal charting
B) Charting by exception
C) Objective data charting
D) Progress notes

Question 26

The respiratory care practitioner's evaluation of the goals of bronchial hygiene should include _______________________.
I.production of sputum following coughing.
II.assessment of clinical improvement.
III.stabilization of pulmonary hygiene with chronic pulmonary disease and a history of secretion retention

A) I only
B) II and III
C) I and III
D) I, II, and III

Question 27

Upon entering a severe asthmatic's room to deliver bronchodilator therapy,the patient expresses displeasure with his physician and the hospital.What should the practitioner do at this time?