Exam 11: Documentation and Goals Assessment

A patient with COPD who has oxygen and a nebulizer at home is ready to be discharged.The practitioner enters the patient's room to reinforce previous directions.The patient states he knows how to use the home care devices and how they are to be used.How should the practitioner proceed with the instructions?

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Question 1

Correct Answer:

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The patient's reluctance to hear anymore instructions should suggest to the practitioner that he needs to proceed with care.Communication is a two-way street,so the patient and the practitioner need to take an active role in the communication process.When the patient verbalizes reluctance to receive anymore instructions,the practitioner must attempt to understand what the patient is saying and not over-react.The practitioner could attempt to put the patient at ease with good eye contact and staying out of the patient's personal space.Feedback from the patient should be sought to ensure any instructions were not misunderstood and that the message was accepted the way it was intended.If possible,the patient should be observed self-administering the medication and cleaning the equipment.The patient should also restate how the oxygen is to be used.Written instructions could be left with the patient.All instructions and any problems anticipated need to be documented in the patient's medical record.The family (or caregiver)should also be involved in the instructions.

Information provided to the physician by the patient is _______________________.

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(Multiple Choice)

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Question 2

Correct Answer:

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When attempting to achieve ventilation goals the respiratory care practitioner should assess the ________________.

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(Multiple Choice)

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Question 3

Correct Answer:

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What is the method of charting that usually employs fill-in-the-blank forms where only data that change are documented?

(Multiple Choice)

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Question 4

Upon entering a severe asthmatic's room to deliver bronchodilator therapy,the patient expresses displeasure with his physician and the hospital.What should the practitioner do at this time?

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Question 5

How are medications recorded in the patient's chart?

(Multiple Choice)

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Question 6

Where are the consents for surgery contained in the patient's chart?

(Multiple Choice)

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Question 7

Which of the following is found in the discharge plan? I.Any prescribed medication II.Teaching for prescribed medication III.Laboratory results

(Multiple Choice)

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Question 8

Which part of the chart contains temperature,pulse,respiration,blood pressure,urine output,oral intake (fluids),and daily weights?

(Multiple Choice)

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Question 9

What is the purpose of the medical record?

(Multiple Choice)

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Question 10

A patient was given a respiratory treatment by a practitioner who did not chart the treatment immediately on the patient's chart due to an excessive workload.Ultimately,the treatment was not charted on the medical record.What problem is associated with the therapist's judgement?

(Essay)

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Question 11

Which of the following is NOT true about the patient's medical record?

(Multiple Choice)

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Question 12

Which of the following are recorded in the patient's record? I.Tests II.Treatments III.Procedures IV.Assessments

(Multiple Choice)

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Question 13

Which of the following represents falsification of the medical record? I.Concealment of an incident II.Making up ventilator settings III.Charting an arterial blood gas that wasn't done

(Multiple Choice)

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Question 14

Which of the following are NOT included in imaging reports?

(Multiple Choice)

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Question 15

What are measurable,demonstrated outcomes that can be assessed following patient treatment or intervention?

(Multiple Choice)

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Question 16

The respiratory care practitioner's evaluation of the goals of bronchial hygiene should include _______________________. I.production of sputum following coughing. II.assessment of clinical improvement. III.stabilization of pulmonary hygiene with chronic pulmonary disease and a history of secretion retention

(Multiple Choice)

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Question 17

Why are the medical record is used by third-party payers?

(Multiple Choice)

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Question 18

How is the history of the patient obtained by the physician?

(Multiple Choice)

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Question 19

What are measurable outcomes the patient is expected to achieve following the intervention of a health care practitioner?

(Multiple Choice)

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Question 20

Showing 1 - 20 of 27

Exam 11: Documentation and Goals Assessment

Information provided to the physician by the patient is _______________________.

When attempting to achieve ventilation goals the respiratory care practitioner should assess the ________________.

What is the method of charting that usually employs fill-in-the-blank forms where only data that change are documented?

Upon entering a severe asthmatic's room to deliver bronchodilator therapy,the patient expresses displeasure with his physician and the hospital.What should the practitioner do at this time?

How are medications recorded in the patient's chart?

Where are the consents for surgery contained in the patient's chart?

Which of the following is found in the discharge plan? I.Any prescribed medication II.Teaching for prescribed medication III.Laboratory results

Which part of the chart contains temperature,pulse,respiration,blood pressure,urine output,oral intake (fluids),and daily weights?

What is the purpose of the medical record?

A patient was given a respiratory treatment by a practitioner who did not chart the treatment immediately on the patient's chart due to an excessive workload.Ultimately,the treatment was not charted on the medical record.What problem is associated with the therapist's judgement?

Which of the following is NOT true about the patient's medical record?

Which of the following are recorded in the patient's record? I.Tests II.Treatments III.Procedures IV.Assessments

Which of the following represents falsification of the medical record? I.Concealment of an incident II.Making up ventilator settings III.Charting an arterial blood gas that wasn't done

Which of the following are NOT included in imaging reports?

What are measurable,demonstrated outcomes that can be assessed following patient treatment or intervention?

Why are the medical record is used by third-party payers?

How is the history of the patient obtained by the physician?

What are measurable outcomes the patient is expected to achieve following the intervention of a health care practitioner?

Basics of Asepsis

Basic Patient Assessment: Vital Signs and Breath Sounds

Advanced Patient Assessment: Inspection, Palpation, and Percussion

Radiologic Assessment

Pulmonary Function Testing

Electrocardiography

Phlebotomy

Arterial Blood Gas Sampling

Hemodynamic Monitoring

Noninvasive Monitoring

Oxygen Supply Systems

Oxygen Administration

Introduction to Respiratory Care Pharmacology

Humidity and Aerosol Therapy

Bronchial Hygiene Therapy

Hyperinflation Therapy

Bronchoscopy Assisting

Equipment Processing and Surveillance

Emergency Airway Management

Artificial Airway Care

Chest Tubes

Insertion and Maintenance of Intravenous Lines

Noninvasive Positive-Pressure Ventilation

Continuous Mechanical Ventilation

Advanced Modes of Mechanical Ventilation

Wave Form Analysis

Weaning and Discontinuance of Mechanical Ventilation

Neonatal Mechanical Ventilation

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