Question 1

According to experts, obtaining a good _____________ from a patient can give you a reasonable chance of correctly identifying a patient's problem before you do a single test.

Accepted Answer

A)   arterial blood gas (ABG)  results
B)   chief complaint
C)   medical history
D)   appearance C

Question 2

Which of the following words are consistent with the definition of the SOAP charting method?
1) Subjective
2) Objective
3) Assessment
4) Physical examination

Accepted Answer

A)  1 and 2
B)  3 and 4
C)  1, 2, and 3
D)  2, 3, and 4 C

Question 3

Which of the following sections of the patient assessment or procedures should be charted immediately?

Accepted Answer

A)   Date and time of test or treatment
B)   Vital signs
C)   Result of or response to treatment, including adverse reactions
D)   Drugs and their dosages B

Question 4

Which of the following methods of documentation is probably best for a clinician who is pressed for time?

Accepted Answer

A)   SOAP
B)   APIE
C)   PIP
D)   SBAR

Question 5

Which of the following organizations influences what needs to be documented in a patient's medical record?

Accepted Answer

A)   The Joint Commission
B)   Center for Medicare and Medicaid Services (CMS) 
C)   Financial intermediaries
D)   Hospital administration

Question 6

Which of the following are advantages of the EMR?
1) Standardization among all hospital systems
2) Increased storage capacity
3) Information is concurrently available even at remote sites
4) Increased accuracy

Accepted Answer

A)  1 and 3
B)  2 and 3
C)  1, 2, and 4
D)  2, 3, and 4

Question 7

What does the letter I stand for in the APIE method of documentation?

Accepted Answer

A)   Implementation
B)   Impact
C)   Inconsistencies
D)   Initiative

Question 8

Which of the following charting methods has been promoted with implementation of rapid response teams (RRTs)?

Accepted Answer

A)   PIP
B)   SOAP
C)   SBAR
D)   APIE

Question 9

Which of the following data constitute part of the objective information section in the SOAP charting method?
1) Vital signs
2) Review of symptoms patient is complaining of
3) Review of clinical laboratory data
4) Review of pulmonary function test results

Accepted Answer

A)  1 and 3
B)  2 and 3
C)  2 and 4
D)  1, 3, and 4

Question 10

Which of the following conditions are required for the legal definition of negligence?
1) The defendant owed a duty of care to the plaintiff.
2) The defendant breached that duty.
3) The plaintiff suffered a legally recognizable injury.
4) The defendant's breach of duty of care did not cause the plaintiff's injury.

Accepted Answer

A)  1 and 2
B)  3 and 4
C)  1, 2, and 3
D)  2, 3, and 4

Question 11

The absence of information or the lack of documented recognition of specific problems could result in which one of the following situations?

Accepted Answer

A)   Malpractice
B)   Reduction in salary for an RT
C)   Reduction in workload
D)   Probation status for the clinician at fault

Question 12

The patient's medical record can be considered which of the following?
1) A communication tool
2) A legal document
3) A part of their records they can take home following discharge
4) An educational tool

Accepted Answer

A)  1 and 3
B)  2 and 3
C)  1, 2, and 4
D)  2, 3, and 4

Question 13

Which of the following are examples of "objective" data?
1) Laboratory results
2) Observation of a patient's sleep apnea
3) The patient's report of the amount of sputum that he or she produces daily
4) The physician's interpretation of the patient's electrocardiogram (ECG)

Accepted Answer

A)  1 and 3
B)  2 and 3
C)  1, 2, and 4
D)  2, 3, and 4

Question 14

Which of the following outlines the professional standards for respiratory therapists (RTs)?
1) American Association for Respiratory Care (AARC) clinical practice guidelines
2) Respiratory care practice act and regulations
3) College granting degree
4) The Joint Commission

Accepted Answer

A)  2 and 4
B)  1 and 3
C)  1, 2, and 4
D)  1, 2, and 3

Question 15

Which of the following is considered the primary goal of The Joint Commission?

Accepted Answer

A)   Monitor financial reimbursement of hospitals.
B)   Review health care organizations to improve the quality of health care and patient safety.
C)   Provide health care workers with a safe work environment.
D)   Monitor the ethical practice of medicine at health care organizations.

Question 16

The major purpose of the electronic medical record (EMR) includes which of the following?

Accepted Answer

A)   Increase efficiencies in the health care system.
B)   Improve the quality of patient care.
C)   Increase patient safety.
D)   All of the above.

Question 17

What does the letter S stand for in the SBAR method of documentation?

Accepted Answer

A)   Subjective
B)   Situation
C)   Severity
D)   Significance

Question 18

Which of the following definitions is consistent with negligence?

Accepted Answer

A)   Failure to document a procedure performed on a patient
B)   Failure to explain to a patient the purpose of a therapy
C)   Failure to obtain a license to practice despite good clinical performance
D)   Failure to use a reasonable amount of care that results in injury or damage to another

Exam 21: Documentation of the Patient Assessment

According to experts, obtaining a good _____________ from a patient can give you a reasonable chance of correctly identifying a patient's problem before you do a single test.

Which of the following words are consistent with the definition of the SOAP charting method? 1) Subjective 2) Objective 3) Assessment 4) Physical examination

Which of the following sections of the patient assessment or procedures should be charted immediately?

Which of the following methods of documentation is probably best for a clinician who is pressed for time?

Which of the following organizations influences what needs to be documented in a patient's medical record?

Which of the following are advantages of the EMR? 1) Standardization among all hospital systems 2) Increased storage capacity 3) Information is concurrently available even at remote sites 4) Increased accuracy

What does the letter I stand for in the APIE method of documentation?

Which of the following charting methods has been promoted with implementation of rapid response teams (RRTs) ?

Which of the following data constitute part of the objective information section in the SOAP charting method? 1) Vital signs 2) Review of symptoms patient is complaining of 3) Review of clinical laboratory data 4) Review of pulmonary function test results

The absence of information or the lack of documented recognition of specific problems could result in which one of the following situations?

The patient's medical record can be considered which of the following? 1) A communication tool 2) A legal document 3) A part of their records they can take home following discharge 4) An educational tool

Which of the following are examples of "objective" data? 1) Laboratory results 2) Observation of a patient's sleep apnea 3) The patient's report of the amount of sputum that he or she produces daily 4) The physician's interpretation of the patient's electrocardiogram (ECG)

Which of the following outlines the professional standards for respiratory therapists (RTs) ? 1) American Association for Respiratory Care (AARC) clinical practice guidelines 2) Respiratory care practice act and regulations 3) College granting degree 4) The Joint Commission

Which of the following is considered the primary goal of The Joint Commission?

The major purpose of the electronic medical record (EMR) includes which of the following?

What does the letter S stand for in the SBAR method of documentation?

Which of the following definitions is consistent with negligence?