Question 1

When the respiratory therapist is entering a SOAPIER progress note in a patient's chart, the A stands for:

Accepted Answer

A)   application of the data.
B)   acceptance of the treatment options by the patient.
C)   affect of the patient.
D)   assessment of the data by the respiratory therapist. D

Question 2

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

Accepted Answer

A)   hemodynamic data.
B)   patient's admission complaint.
C)   blood pressure.
D)   sputum production. B

Question 3

Which agency should be notified if violations of HIPAA regulations have occurred?

Accepted Answer

A)   HHS
B)   FDA
C)   CDC
D)   Joint Commission A

Question 4

In which section of the SOAPIER format should the patient's response to a specific treatment modality be recorded?

Accepted Answer

A)   Assessment
B)   Implementation
C)   Observation
D)   Evaluation

Question 5

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

Accepted Answer

A)   revisions made in the original plan.
B)   reimbursement by the insurance carrier.
C)   respiratory care notes.
D)   resuscitation status of the patient.

Question 6

Which of the following statements is TRUE regarding Health Insurance Portability and Accountability Act (HIPAA) regulations?

Accepted Answer

A)   A bank can check for a preexisting condition.
B)   The patient controls access to his or her medical records.
C)   Psychotherapy and medical records are treated equally.
D)   An employer can check for a preexisting condition.

Question 7

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.

Accepted Answer

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

Question 8

All of the following statements are true regarding a patient's chart EXCEPT:

Accepted Answer

A)   the patient's chart is a legal record and can be used in court.
B)   accreditation agencies may access a patient's chart to assess appropriateness of care.
C)   the patient's insurance company may review the patient's chart before providing reimbursement.
D)   the patient's spouse may access the patient's chart without authorization by the patient.

Question 9

Which of the following are basic methods to record assessment data?
1) Computer documentation
2) Block chart
3) Source-oriented record
4) Problem-oriented medical record

Accepted Answer

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

Question 10

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) Ordering patient supplies

Accepted Answer

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

Exam 11: Recording Skills: The Basis for Data Collection, Organization, Assessment Skill