Question 1

To determine any recent trends in a patient's pulse, respiration, or blood pressure, you would go to which section of the medical record?

Accepted Answer

Vital signs, including pulse, respiration, and blood pressure measurements, are typically recorded on a vital signs sheet, making it the best choice for determining recent trends in these parameters. Progress notes may also include information about vital signs, but they may not be as consistently measured and recorded as they are on a separate vital signs sheet. Nurses' notes and anesthesia records may contain information about vital signs at specific times but may not provide a comprehensive overview of recent trends.

Question 2

To determine the most recent medical status of a patient whom you are about to start treating, you would go to which section of the medical record?

Accepted Answer

The progress sheet in a medical record provides the most current information about a patient's medical status, including updates on their condition, treatment responses, and any changes in their health status since admission or since the last evaluation.

Question 3

A pulmonary specialist has been called in by an internist to examine a patient and help make a diagnosis. Where in the patient's medical record would you look for the pulmonary specialist's report?

Accepted Answer

The pulmonary specialist's report would most likely be found in the consultation sheet, as this is typically where the notes and assessments of consultants are documented in the patient's medical record. The progress sheet may have updates on the patient's condition, but not specifically related to the consultation with the pulmonary specialist. The physician's orders would include any specific instructions for treatment or medications, but not necessarily the specialist's diagnosis. The history and physical exam is typically completed by the internist, and may not include the specialist's input.

Question 4

If you make a mistake when charting a patient treatment, what should you do?

Accepted Answer

Drawing a line through the mistake and labeling it as an error is the best way to make a correction in patient charting. This maintains the integrity of the original chart while also clearly marking the mistake for future reference. Erasing or making new entries can create confusion and potential legal issues. Having a supervisor make the correction later is impractical and can cause a delay in important patient care.

Question 5

Which of the following are unacceptable practices in medical recordkeeping?
I.specifying when you will return to provide patient therapy
II.providing your own interpretation of a patient's symptoms
III.recording the patient's complaints and general behavior
IV.charting several separate tasks under a single chart entry

Accepted Answer

II and IV are unacceptable practices. Providing your own interpretation of a patient's symptoms can lead to bias and misdiagnosis, while charting several tasks under a single entry can create confusion and inaccuracies in the patient's medical record.

Question 6

Which of the following is an acceptable practice in medical recordkeeping?

Accepted Answer

Using standard abbreviations is an acceptable and common practice in medical recordkeeping. Leaving blank lines can lead to confusion or errors, erasing incorrect entries can raise legal and ethical issues, and ditto marks are not considered acceptable in modern recordkeeping practices.

Question 7

To find out what drugs or intravenous fluids a patient has received recently, you would go to which section of the medical record?

Accepted Answer

The medication record section of the medical record contains information about the drugs or intravenous fluids that a patient has received recently.

Question 8

Which of the following is the correct way to sign a medical record entry?

Accepted Answer

C. White, LRCP, CRTThe correct way to sign a medical record entry includes the use of initials or full name, along with the relevant credentials. Option C provides a clear identification of the individual (C. White) and includes professional credentials (LRCP, CRT), which is essential for verifying the qualifications of the person making the entry.

Question 9

To confirm a physician's prescription for a drug that you need to give to a patient, you would go to which section of the medical record?

Accepted Answer

Physician's orders section of the medical record contains the instructions by the physician for the medications to be dispensed to the patient.

Question 10

What is a time-based record of measurement during a specialized procedure such as mechanical ventilation?

Accepted Answer

A specialized flowsheet is used to record time-based measurements during specific procedures like mechanical ventilation, allowing for detailed tracking of patient data over time.

Question 11

To determine the amount of urine excreted by a patient in the last 24 hours, you would go to which section of the medical record?

Accepted Answer

The intake and output (I & O) sheet is specifically used to document the amount of fluid a patient has taken in (intake) as well as the amount of fluid that has been eliminated from their body (output), including urine. Therefore, it would be the most appropriate section in the medical record to find information on the patient's urine output in the last 24 hours.

Question 12

To check on the results of a patient's recent blood work, you would go to which section of the medical record?

Accepted Answer

Laboratory sheets are specifically designed to display the results of any lab work performed on a patient. This would include any recent blood work.

Quiz 3: Patient Safety, Communication, and Record Keeping