Question 1

What is the purpose of the medical record?

Accepted Answer

A) It is temporary proof of the nature of care,quality of care,and timeliness of care. 
B) It is the one place where all pertinent medical information on a patient is recorded and accessible to all health care professionals caring for that patient. 
C) It is an approximate record of the patient's condition,illness,and treatment. 
D) To provide a written source of information regarding that patient providing a common source of information for all caregivers. 
A) It is temporary proof of the nature of care,quality of care,and timeliness of care. 
B) It is the one place where all pertinent medical information on a patient is recorded and accessible to all health care professionals caring for that patient. 
C) It is an approximate record of the patient's condition,illness,and treatment. 
D) To provide a written source of information regarding that patient providing a common source of information for all caregivers. D

Question 2

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

Accepted Answer

A) Goals 
B) Objectives 
C) Assessments 
D) Procedures 
A) Goals 
B) Objectives 
C) Assessments 
D) Procedures A

Question 3

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 A

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?

Accepted Answer

Effective communication is necessary to

Question 5

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

Accepted Answer

A) Physician's Orders 
B) History and Physical Examination 
C) Multidisciplinary Records 
D) Graphic Record 
A) Physician's Orders 
B) History and Physical Examination 
C) Multidisciplinary Records 
D) Graphic Record

Question 6

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

Accepted Answer

A) PaO₂ . 
B) SaO₂ . 
C) PaCO₂ . 
D) HCO₃. 
A) PaO₂ . 
B) SaO₂ . 
C) PaCO₂ . 
D) HCO₃.

Question 7

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 8

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

Accepted Answer

A) I and II 
B) I only 
C) II and III 
D) I,II,and III 
A) I and II 
B) I only 
C) II and III 
D) I,II,and III

Question 9

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

Accepted Answer

A) I and II only 
B) II and III only 
C) I,III,and IV 
D) I,II,III,and IV 
A) I and II only 
B) II and III only 
C) I,III,and IV 
D) I,II,III,and IV

Question 10

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 11

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

Question 12

Which of the following are NOT included in imaging reports?

Accepted Answer

A) Ultrasound 
B) Surgery 
C) Chest radiographs 
D) Magnetic resonance imaging scans 
A) Ultrasound 
B) Surgery 
C) Chest radiographs 
D) Magnetic resonance imaging scans

Question 13

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 14

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

Accepted Answer

A) From the patient 
B) From the physical examination 
C) From the patient's family 
D) a and c 
A) From the patient 
B) From the physical examination 
C) From the patient's family 
D) a and c

Question 15

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

Accepted Answer

A) Clinical goal charting 
B) Charting by exception 
C) Objective data charting 
D) Progress notes 
A) Clinical goal charting 
B) Charting by exception 
C) Objective data charting 
D) Progress notes

Question 16

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?

Accepted Answer

The patient's reluctance to hear anymore

Question 17

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

Accepted Answer

A) It serves as legal proof of the nature of care,quality of care,and timeliness of care. 
B) It is the only source on a given patient referred to by all health care professionals 
C) The hospital may use it for risk management,reimbursement purposes,or research purposes among others. 
D) Assessment(s),treatment(s),procedure(s),and test(s)are all recorded in it. 
A) It serves as legal proof of the nature of care,quality of care,and timeliness of care. 
B) It is the only source on a given patient referred to by all health care professionals 
C) The hospital may use it for risk management,reimbursement purposes,or research purposes among others. 
D) Assessment(s),treatment(s),procedure(s),and test(s)are all recorded in it.

Question 18

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

Accepted Answer

A) Clinical goals 
B) Charting by exception 
C) Objective data 
D) Progress notes 
A) Clinical goals 
B) Charting by exception 
C) Objective data 
D) Progress notes

Question 19

Information provided to the physician by the patient is _______________________.

Accepted Answer

A) contained in the progress notes. 
B) always confidential. 
C) objective data. 
D) subjective data 
A) contained in the progress notes. 
B) always confidential. 
C) objective data. 
D) subjective data

Question 20

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

Accepted Answer

A) I only 
B) II and III 
C) I and III 
D) I,II,and III 
A) I only 
B) II and III 
C) I and III 
D) I,II,and III

Exam 11: Documentation and Goals Assessment

What is the purpose of the medical record?

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

Which of the following is NOT true concerning documentation?

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?

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

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

How are entries entered into the medical record?

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

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

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

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?

Which of the following are NOT included in imaging reports?

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?

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

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

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

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

Information provided to the physician by the patient is _______________________.

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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