Question 1

When reviewing a SOAPIER progress note, all of the following would be found in the O area EXCEPT:&#10;A) hemodynamic data.&#10;B)patient's admission complaint.&#10;C)blood pressure.&#10;D)sputum production.

Accepted Answer

The O area of a SOAPIER progress note stands for objective information, which includes measurable data and observations made by the healthcare provider. The patient's admission complaint is subjective information belonging to the S area (subjective) of the note. Hemodynamic data, blood pressure, and sputum production are all objective information that can be recorded in the progress note.

Question 2

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

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

1, 3, 4

Accepted Answer

A problem-oriented medical record (POMR) is a standardized approach to medical record-keeping that focuses on identifying and managing patients' health problems. The key elements of a POMR include a database, a problem list, progress notes, and a plan of care. The database is used to systematically gather the patient's data, including medical history, physical examination findings, laboratory and imaging results, and other relevant information. The problem list is a concise summary of the patient's identified health problems, and the progress notes and plan of care are used to develop an assessment and formulate a treatment plan based on the patient's individual needs. While communication with the patient's family may be important in certain situations, it is not a primary focus of the POMR.

Question 3

All of the following blocks of information will be found in a patient's source-oriented record EXCEPT:&#10;A) laboratory reports.&#10;B)history.&#10;C)police record.&#10;D)admission information.

Accepted Answer

A patient's police record would not be included in their medical record as it is not relevant to their medical history or treatment.

Question 4

A patient who had pneumonia, and her family, are suing the hospital, physician, and respiratory therapist. How can the patient's medical care and treatment be proved?&#10;A) Care is documented in the chart.&#10;B)The patient's testimony&#10;C)The physician's testimony&#10;D)The respiratory therapist's testimony

Accepted Answer

The patient's medical care and treatment can be proved through documentation in the patient's medical chart, which includes notes from all healthcare professionals involved in the patient's care. Testimonies from the patient, physician, and respiratory therapist may also be used but the most reliable source is the documented care in the chart.

Question 5

According to the chapter text, which of the following are basic methods to record assessment data?
1) Computer documentation
2) Charting by exception
3) Source-oriented record
4) Problem-oriented medical record

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

Accepted Answer

The answer of According to the chapter text, which of...

Question 6

Which of the following is a Health Insurance Portability and Accountability Act (HIPAA) rule?&#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 rules give patients control over who can access their medical records, including health care providers, insurance companies, and employers. Therefore, option B is correct, while options A, C, and D are incorrect.

Question 7

Many respiratory therapists now use portable devices for bedside computer charting. These units are referred to as:&#10;A) point-of-care systems.&#10;B)laptop computers.&#10;C)i-pods.&#10;D)MP3 players.

Accepted Answer

Portable devices used by respiratory therapists for bedside computer charting are referred to as point-of-care systems. These systems allow for efficient and accurate charting at the patient's bedside, eliminating the need for paper charting and improving patient care. Laptop computers may also be used, but they may not be as convenient or efficient as a specifically designed point-of-care system. i-pods and MP3 players are not typically used for this purpose.

Question 8

When reviewing a SOAPIER progress note, the A stands for:&#10;A) application of the data.&#10;B)assessment of the data by the patient.&#10;C)affect of the patient.&#10;D)assessment of the data by the health-care worker.

Accepted Answer

The A in SOAPIER stands for "assessment of the data by the health-care worker." This refers to the healthcare professional's evaluation of the information gathered during the patient encounter. The healthcare worker reviews the patient's symptoms, signs, and medical history to form a clinical judgment about the patient's condition.

Question 9

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) Playing back recorded patient interviews

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

Accepted Answer

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) Playing back recorded patient interviews

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

Question 10

When reviewing a SOAPIER progress note, the R stands for:&#10;A) revisions made in the original plan.&#10;B)refusal of care by the patient.&#10;C)rejection by the physician.&#10;D)resuscitate the patient.

Accepted Answer

In the SOAPIER format, the R stands for revisions made in the original plan. This means that any changes or modifications made to the treatment plan are documented in this section of the progress note.

Deck 10: Recording Skills: the Basis for Data Collection, Organization, Assessment Skills, and Treatment Plans