Exam 21: Documentation of the Patient Assessment

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.

Which of the following words are consistent with the definition of the SOAP charting method? 1) Subjective 2) Objective 3) Assessment 4) Physical examination

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

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

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

Which of the following are advantages of the EMR? 1) Standardization among all hospital systems 2) Increased storage capacity 3) Information is concurrently available even at remote sites 4) Increased accuracy

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

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

Which of the following data constitute part of the objective information section in the SOAP charting method? 1) Vital signs 2) Review of symptoms patient is complaining of 3) Review of clinical laboratory data 4) Review of pulmonary function test results

Which of the following conditions are required for the legal definition of negligence? 1) The defendant owed a duty of care to the plaintiff. 2) The defendant breached that duty. 3) The plaintiff suffered a legally recognizable injury. 4) The defendant's breach of duty of care did not cause the plaintiff's injury.

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

The patient's medical record can be considered which of the following? 1) A communication tool 2) A legal document 3) A part of their records they can take home following discharge 4) An educational tool

Which of the following are examples of "objective" data? 1) Laboratory results 2) Observation of a patient's sleep apnea 3) The patient's report of the amount of sputum that he or she produces daily 4) The physician's interpretation of the patient's electrocardiogram (ECG)

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) College granting degree 4) The Joint Commission

Which of the following is considered the primary goal of The Joint Commission?

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

What does the letter S stand for in the SBAR method of documentation?

Which of the following definitions is consistent with negligence?