Question 1

Computer-based records are commonly used for which of the following?
1) Retrieving pulmonary function studies
2) Storing treatment information
3) Storing admission data
4) Ordering patient supplies

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

1, 2, 3

Accepted Answer

Computer-based records are commonly used for retrieving pulmonary function studies, storing treatment information, and storing admission data, making all these tasks more efficient and accessible.

Question 2

Which of the following statements are true regarding a patient's chart?
1) The patient's chart is a legal record and can be used in court.
2) Accreditation agencies may access a patient's chart to assess appropriateness of care.
3) The patient's insurance company may review the patient's chart before providing reimbursement.
4) The patient's spouse may access the patient's chart without authorization by the patient.

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

1, 2, 3

Accepted Answer

1) Patient charts are indeed legal documents that can be subpoenaed and used as evidence in court proceedings. 2) Accreditation agencies, such as The Joint Commission, review patient charts to ensure healthcare providers meet certain standards of care. 3) Insurance companies often review patient charts to verify the medical necessity of services before they authorize reimbursement. 4) Access to a patient's chart by a spouse or any other family member without explicit authorization from the patient violates privacy laws, such as HIPAA in the United States, unless specific legal conditions are met (e.g., the patient is a minor or incapacitated and the spouse is the legal guardian).

Question 3

In which section of the SOAPIER format should the patient's response to a specific treatment modality be recorded?&#10;A) Assessment&#10;B) Implementation&#10;C) Observation&#10;D) Evaluation

Accepted Answer

In the SOAPIER format, the Evaluation section is where the healthcare provider records the patient's response to a specific treatment modality, assessing its effectiveness and making necessary adjustments.

Question 4

Which of the following are basic methods to record assessment data?
1) Computer documentation
2) Block chart
3) Traditional chart
4) Problem-oriented medical record

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

Accepted Answer

1) Computer documentation, 3) Traditional chart, and 4) Problem-oriented medical record are basic methods to record assessment data. Computer documentation allows for digital record-keeping, traditional charts are a conventional method of recording data, and problem-oriented medical records organize information based on the patient's specific issues. Block charts are not typically used for recording individual patient assessment data.

Question 5

Telemedicine allows health care practitioner the ability to do which of the following?
1) Perform remote procedures using robotics.
2) Attend medical education seminars.
3) Send and receive patient medical files, radiologic images, and health informatics data.
4) Conduct real-time interactive videoconferencing with patients, other care givers, and consultants.

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

Accepted Answer

Telemedicine allows health care practitioner the ability to do which of the following?
1) Perform remote procedures using robotics.
2) Attend medical education seminars.
3) Send and receive patient medical files, radiologic images, and health informatics data.
4) Conduct real-time interactive videoconferencing with patients, other care givers, and consultants.

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

Question 6

Which agency should be notified if violations of HIPAA regulations have occurred?&#10;A) HHS&#10;B) FDA&#10;C) CDC&#10;D) The Joint Commission

Accepted Answer

The Department of Health and Human Services (HHS) is responsible for enforcing HIPAA regulations, so any violations should be reported to them.

Question 7

When reviewing a SOAPIER progress note, the R stands for:&#10;A) revisions made in the original plan.&#10;B) reimbursement by the insurance carrier.&#10;C) respiratory care notes.&#10;D) resuscitation status of the patient.

Accepted Answer

In the SOAPIER progress note format, the "R" stands for "Revisions made in the original plan." This step involves updating or modifying the care plan based on the patient's progress and any new information that has come to light.

Question 8

Which of the following statements is true regarding Health Insurance Portability and Accountability Act (HIPAA) regulations?&#10;A) A bank can check for a preexisting condition.&#10;B) The patient controls access to his/her medical records.&#10;C) Psychotherapy and medical records are treated equally.&#10;D) An employer can check for a preexisting condition.

Accepted Answer

HIPAA gives patients the right to access their own medical records, control who else can access them, and make corrections to them. This ensures that individuals have control over their personal health information.

Question 9

When reviewing a SOAPIER progress note, all of the following would be found in the S area?&#10;A) Hemodynamic data&#10;B) Patient's admission complaint&#10;C) Blood pressure&#10;D) Sputum production

Accepted Answer

The "S" in SOAPIER stands for Subjective data, which includes information the patient verbally communicates, such as their admission complaint. Hemodynamic data, blood pressure, and sputum production are examples of objective data, not subjective.

Question 10

A problem-oriented medical record is used by health care practitioners to:
1) systemically gather clinical data.
2) communicate with the patient's family.
3) develop a treatment plan.
4) formulate an assessment.

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

Accepted Answer

Problem-oriented medical records are designed to systematically gather clinical data (1), develop a treatment plan (3), and formulate an assessment (4), facilitating a structured and efficient approach to patient care.

Question 11

When the respiratory therapist is entering a SOAPIER progress note in a patient's chart, the A stands for:&#10;A) application of the data.&#10;B) acceptance of the treatment options by the patient.&#10;C) affect of the patient.&#10;D) assessment of the data by the respiratory therapist.

Accepted Answer

The answer of When the respiratory therapist is entering a...

Deck 12: Recording Skills and Intra-Professional Communication