Exam 10: Recording Skills: the Basis for Data Collection, Organization, Assessment Skills, and Treatment Plans

Many respiratory therapists now use portable devices for bedside computer charting. These units are referred to as:

When reviewing a SOAPIER progress note, all of the following would be found in the O area EXCEPT:

Computer-based records are commonly used for which of the following? 1) Retrieving pulmonary function studies 2) Storing treatment information 3) Storing admission data 4) Playing back recorded patient interviews

When reviewing a SOAPIER progress note, the R stands for:

All of the following blocks of information will be found in a patient's source-oriented record EXCEPT:

A patient who had pneumonia, and her family, are suing the hospital, physician, and respiratory therapist. How can the patient's medical care and treatment be proved?

A problem-oriented medical record is used by health-care practitioners to: 1) systemically gather the patient's data. 2) communicate with the patient's family. 3) develop an assessment. 4) formulate a treatment plan.

When reviewing a SOAPIER progress note, the A stands for:

According to the chapter text, which of the following are basic methods to record assessment data? 1) Computer documentation 2) Charting by exception 3) Source-oriented record 4) Problem-oriented medical record

Which of the following is a Health Insurance Portability and Accountability Act (HIPAA) rule?