Question 1

Which part of the medical record states the date and time the patient was admitted to the acute care facility as well as the patient's medical diagnosis?

Accepted Answer

A)  Physician's orders 
B)  Progress notes 
C)  Admission record 
D)  Medical history 
A)  Physician's orders 
B)  Progress notes 
C)  Admission record 
D)  Medical history

Question 2

Which of the following is NOT found in the laboratory reports?

Accepted Answer

A)  Computerized tomography reports 
B)  Arterial blood gas reports 
C)  Hematology reports 
D)  Endocrinology reports 
A)  Computerized tomography reports 
B)  Arterial blood gas reports 
C)  Hematology reports 
D)  Endocrinology reports

Question 3

Legally,if an event is not documented in the patient's medical record,_______________.

Accepted Answer

A)  it can be documented up to one week after the event. 
B)  it can be charged to the patient's hospital bill. 
C)  it was not done. 
D)  it is valid only if the patient remembers the event. 
A)  it can be documented up to one week after the event. 
B)  it can be charged to the patient's hospital bill. 
C)  it was not done. 
D)  it is valid only if the patient remembers the event.

Question 4

Vital signs,breath sounds,jugular venous distention,heart tones,SpO₂,and bowel sounds are all examples of _________________.

Accepted Answer

A)  objective data. 
B)  subjective data. 
C)  clinical goals. 
D)  graphic records. 
A)  objective data. 
B)  subjective data. 
C)  clinical goals. 
D)  graphic records.

Question 5

How are entries entered into the medical record?

Accepted Answer

A)  In chronological order 
B)  In random order 
C)  In order of department 
D)  Alphabetical order 
A)  In chronological order 
B)  In random order 
C)  In order of department 
D)  Alphabetical order

Question 6

Which of the following is NOT true concerning documentation?

Accepted Answer

A)  Document things in anticipation of doing it 
B)  The date and time of interaction 
C)  Accuracy, timeliness, and truthfulness all are important 
D)  Document only what has been performed 
A)  Document things in anticipation of doing it 
B)  The date and time of interaction 
C)  Accuracy, timeliness, and truthfulness all are important 
D)  Document only what has been performed

Question 7

What is a compilation of pertinent facts of a patient's life and health history,illness(es),and treatment(s)written by health care professionals who have contributed to the care of that patient?

Accepted Answer

A)  Risk management 
B)  The medical record 
C)  Clinical goals 
D)  Physician's orders 
A)  Risk management 
B)  The medical record 
C)  Clinical goals 
D)  Physician's orders

Which part of the medical record states the date and time the patient was admitted to the acute care facility as well as the patient's medical diagnosis?

Which of the following is NOT found in the laboratory reports?

Legally,if an event is not documented in the patient's medical record,_______________.

Vital signs,breath sounds,jugular venous distention,heart tones,SpO₂,and bowel sounds are all examples of _________________.

How are entries entered into the medical record?

Which of the following is NOT true concerning documentation?

What is a compilation of pertinent facts of a patient's life and health history,illness(es),and treatment(s)written by health care professionals who have contributed to the care of that patient?

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

Filters

Exam 11: Documentation and Goals Assessment

Which part of the medical record states the date and time the patient was admitted to the acute care facility as well as the patient's medical diagnosis?

Which of the following is NOT found in the laboratory reports?

Legally,if an event is not documented in the patient's medical record,_______________.

Vital signs,breath sounds,jugular venous distention,heart tones,SpO₂,and bowel sounds are all examples of _________________.

How are entries entered into the medical record?

Which of the following is NOT true concerning documentation?

What is a compilation of pertinent facts of a patient's life and health history,illness(es),and treatment(s)written by health care professionals who have contributed to the care of that patient?

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

Filters