Deck 21: Documentation of the Patient Assessment

Question 1

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

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

Answer 1

Implementation

Question 2

Which of the following definitions is consistent with negligence?

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

Answer 2

Failure to use a reasonable amount of care that results in injury or damage to another

Question 3

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

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

Answer 3

2, 3, and 4

Question 4

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

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

Question 5

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

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

Question 6

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.

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

Question 7

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

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

Question 8

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

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

Question 9

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

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

Question 10

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)

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

Question 11

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

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 12

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

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

Question 13

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

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 14

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

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

Question 15

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

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

Question 16

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

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

Question 17

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.

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

Question 18

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

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