Exam 11: Documentation and Goals Assessment

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

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

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

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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

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

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How are medications recorded in the patient's chart?

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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?

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