Question 1

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

Accepted Answer

A) SOAP 
B) APIE 
C) PIP 
D) SBAR 
A) SOAP 
B) APIE 
C) PIP 
D) SBAR C

Question 2

Which of the following definitions is consistent with negligence?

Accepted Answer

A) Failure to document a procedure performed on a patient 
B) Failure to explain to a patient the purpose of a therapy 
C) Failure to obtain a license to practice despite good clinical performance 
D) Failure to use a reasonable amount of care that results in injury or damage to another 
A) Failure to document a procedure performed on a patient 
B) Failure to explain to a patient the purpose of a therapy 
C) Failure to obtain a license to practice despite good clinical performance 
D) Failure to use a reasonable amount of care that results in injury or damage to another D

Question 3

What is the primary goal of The Joint Commission?

Accepted Answer

A) Monitor financial reimbursement of hospitals 
B) Review healthcare organizations to improve the quality of healthcare and patient safety 
C) Provide healthcare workers with a safe work environment 
D) Monitor the ethical practice of medicine at healthcare organizations 
A) Monitor financial reimbursement of hospitals 
B) Review healthcare organizations to improve the quality of healthcare and patient safety 
C) Provide healthcare workers with a safe work environment 
D) Monitor the ethical practice of medicine at healthcare organizations B

Question 4

The patient's medical record is a/an:

Accepted Answer

A) financial document. 
B) legal document. 
C) educational tool. 
D) all of the above. 
A) financial document. 
B) legal document. 
C) educational tool. 
D) all of the above.

Question 5

Which of the following conditions is not required for the legal definition of negligence?

Accepted Answer

A) The defendant owed a duty of care to the plaintiff. 
B) The defendant breached that duty. 
C) The plaintiff suffered a legally recognizable injury. 
D) The defendant's breach of duty of care did not cause the plaintiff's injury. 
A) The defendant owed a duty of care to the plaintiff. 
B) The defendant breached that duty. 
C) The plaintiff suffered a legally recognizable injury. 
D) The defendant's breach of duty of care did not cause the plaintiff's injury.

Question 6

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.

Accepted Answer

A) arterial blood gas (ABG) results 
B) chief complaint 
C) medical history 
D) appearance 
A) arterial blood gas (ABG) results 
B) chief complaint 
C) medical history 
D) appearance

Question 7

All of the following are examples of "objective" data, except:

Accepted Answer

A) laboratory results. 
B) observation of a patient's sleep apnea. 
C) the patient's report of the amount of sputum that he or she produces daily. 
D) the physician's interpretation of the patient's electrocardiogram (ECG). 
A) laboratory results. 
B) observation of a patient's sleep apnea. 
C) the patient's report of the amount of sputum that he or she produces daily. 
D) the physician's interpretation of the patient's electrocardiogram (ECG).

Question 8

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)Place of employment
4)The Joint Commission

Accepted Answer

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

Question 9

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

Accepted Answer

A) PIP 
B) SOAP 
C) SBAR 
D) APIE 
A) PIP 
B) SOAP 
C) SBAR 
D) APIE

Question 10

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

Accepted Answer

A) Implementation 
B) Impact 
C) Inconsistencies 
D) Initiative 
A) Implementation 
B) Impact 
C) Inconsistencies 
D) Initiative

Question 11

Which of the following words is not consistent with the definition of the SOAP charting method?

Accepted Answer

A) Subjective 
B) Objective 
C) Assessment 
D) Physical examination 
A) Subjective 
B) Objective 
C) Assessment 
D) Physical examination

Question 12

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

Accepted Answer

A) Increase efficiencies in the healthcare system 
B) Improve the quality of patient care 
C) Increase patient safety 
D) All of the above 
A) Increase efficiencies in the healthcare system 
B) Improve the quality of patient care 
C) Increase patient safety 
D) All of the above

Question 13

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

Accepted Answer

A) Date and time of test or treatment 
B) Vital signs 
C) Result of or response to treatment, including adverse reactions 
D) Drugs and their dosages 
A) Date and time of test or treatment 
B) Vital signs 
C) Result of or response to treatment, including adverse reactions 
D) Drugs and their dosages

Question 14

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

Accepted Answer

A) The Joint Commission 
B) Center for Medicare and Medicaid Services (CMS) 
C) Financial intermediaries 
D) All of the above 
A) The Joint Commission 
B) Center for Medicare and Medicaid Services (CMS) 
C) Financial intermediaries 
D) All of the above

Question 15

All of the following are advantages of the EMR except:

Accepted Answer

A) lack of standardization among systems. 
B) increased storage capacity. 
C) information is concurrently available even at remote sites. 
D) increased accuracy. 
A) lack of standardization among systems. 
B) increased storage capacity. 
C) information is concurrently available even at remote sites. 
D) increased accuracy.

Question 16

Which of the following data do not constitute part of the objective information section in the SOAP charting method?

Accepted Answer

A) Vital signs 
B) Review of systems 
C) Review of clinical laboratory data 
D) Review of pulmonary function test results 
A) Vital signs 
B) Review of systems 
C) Review of clinical laboratory data 
D) Review of pulmonary function test results

Question 17

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

Accepted Answer

A) Malpractice 
B) Reduction in salary for an RT 
C) Reduction in workload 
D) Probation status for the clinician at fault 
A) Malpractice 
B) Reduction in salary for an RT 
C) Reduction in workload 
D) Probation status for the clinician at fault

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

Which of the following definitions is consistent with negligence?

What is the primary goal of The Joint Commission?

The patient's medical record is a/an:

Which of the following conditions is not required for the legal definition of negligence?

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.

All of the following are examples of "objective" data, except:

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)Place of employment 4)The Joint Commission

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

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

Which of the following words is not consistent with the definition of the SOAP charting method?

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

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

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

All of the following are advantages of the EMR except:

Which of the following data do not constitute part of the objective information section in the SOAP charting method?

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

Preparing for the Patient Encounter

The Medical History and the Interview

Cardiopulmonary Symptoms

Vital Signs

Fundamentals of Physical Examination

Neurologic Assessment

Clinical Laboratory Studies

Interpretation of Blood Gases

Pulmonary Function Testing

Chest Imaging

Interpretation of Electrocardiogram Tracings

Neonatal and Pediatric Assessment

Older Patient Assessment

Respiratory Monitoring in Critical Care

Vascular Pressure Monitoring

Cardiac Output Measurement

Bronchoscopy

Nutrition Assessment

Sleep and Breathing Assessment

Home Care Patient Assessment

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Exam 21: Documentation

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

Which of the following definitions is consistent with negligence?

What is the primary goal of The Joint Commission?

The patient's medical record is a/an:

Which of the following conditions is not required for the legal definition of negligence?

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.

All of the following are examples of "objective" data, except:

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)Place of employment 4)The Joint Commission

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

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

Which of the following words is not consistent with the definition of the SOAP charting method?

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

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

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

All of the following are advantages of the EMR except:

Which of the following data do not constitute part of the objective information section in the SOAP charting method?

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

Preparing for the Patient Encounter

The Medical History and the Interview

Cardiopulmonary Symptoms

Vital Signs

Fundamentals of Physical Examination

Neurologic Assessment

Clinical Laboratory Studies

Interpretation of Blood Gases

Pulmonary Function Testing

Chest Imaging

Interpretation of Electrocardiogram Tracings

Neonatal and Pediatric Assessment

Older Patient Assessment

Respiratory Monitoring in Critical Care

Vascular Pressure Monitoring

Cardiac Output Measurement

Bronchoscopy

Nutrition Assessment

Sleep and Breathing Assessment

Home Care Patient Assessment

Filters