Question 1

Upon entering a severe asthmatic's room to deliver bronchodilator therapy,the patient expresses displeasure with his physician and the hospital.What should the practitioner do at this time?

Accepted Answer

Effective communication is necessary to ...

Question 2

How are entries entered into the medical record?

Accepted Answer

A)  In chronological order
B)  In random order
C)  In order of department
D)  Alphabetical order

Question 3

What is a compilation of pertinent facts of a patient's life and health history,illness(es) ,and treatment(s) written by health care professionals who have contributed to the care of that patient?

Accepted Answer

A)  Risk management
B)  The medical record
C)  Clinical goals
D)  Physician's orders

Question 4

Which part of the medical record states the date and time the patient was admitted to the acute care facility as well as the patient's medical diagnosis?

Accepted Answer

A)  Physician's orders
B)  Progress notes
C)  Admission record
D)  Medical history

Question 5

Which of the following are NOT included in imaging reports?

Accepted Answer

A)  Ultrasound
B)  Surgery
C)  Chest radiographs
D)  Magnetic resonance imaging scans

Question 6

How is the history of the patient obtained by the physician?

Accepted Answer

A)  From the patient
B)  From the physical examination
C)  From the patient's family
D)  a and c

Question 7

The respiratory care practitioner's evaluation of the goals of bronchial hygiene should include _______________________.
I.production of sputum following coughing.
II.assessment of clinical improvement.
III.stabilization of pulmonary hygiene with chronic pulmonary disease and a history of secretion retention

Accepted Answer

A)  I only
B)  II and III
C)  I and III
D)  I,II,and III

Question 8

What is the method of charting that usually employs fill-in-the-blank forms where only data that change are documented?

Accepted Answer

A)  Clinical goal charting
B)  Charting by exception
C)  Objective data charting
D)  Progress notes

Question 9

Which of the following is found in the discharge plan?
I.Any prescribed medication
II.Teaching for prescribed medication
III.Laboratory results

Accepted Answer

A)  I and II
B)  I only
C)  II and III
D)  I,II,and III

Question 10

What are measurable,demonstrated outcomes that can be assessed following patient treatment or intervention?

Accepted Answer

A)  Goals
B)  Objectives
C)  Assessments
D)  Procedures A

Question 11

Which part of the chart contains temperature,pulse,respiration,blood pressure,urine output,oral intake (fluids) ,and daily weights?

Accepted Answer

A)  Physician's Orders
B)  History and Physical Examination
C)  Multidisciplinary Records
D)  Graphic Record

Question 12

What are measurable outcomes the patient is expected to achieve following the intervention of a health care practitioner?

Accepted Answer

A)  Clinical goals
B)  Charting by exception
C)  Objective data
D)  Progress notes

Question 13

Which of the following are recorded in the patient's record?
I.Tests
II.Treatments
III.Procedures
IV.Assessments

Accepted Answer

A)  I and II only
B)  II and III only
C)  I,III,and IV
D)  I,II,III,and IV

Question 14

Which of the following is NOT true about the patient's medical record?

Accepted Answer

A)  It serves as legal proof of the nature of care,quality of care,and timeliness of care.
B)  It is the only source on a given patient referred to by all health care professionals
C)  The hospital may use it for risk management,reimbursement purposes,or research purposes among others.
D)  Assessment(s) ,treatment(s) ,procedure(s) ,and test(s) are all recorded in it.

Question 15

Legally,if an event is not documented in the patient's medical record,_______________.

Accepted Answer

A)  it can be documented up to one week after the event.
B)  it can be charged to the patient's hospital bill.
C)  it was not done.
D)  it is valid only if the patient remembers the event.

Question 16

A patient with COPD who has oxygen and a nebulizer at home is ready to be discharged.The practitioner enters the patient's room to reinforce previous directions.The patient states he knows how to use the home care devices and how they are to be used.How should the practitioner proceed with the instructions?

Accepted Answer

The patient's reluctance to hear anymore...

Question 17

What is the purpose of the medical record?

Accepted Answer

A)  It is temporary proof of the nature of care,quality of care,and timeliness of care.
B)  It is the one place where all pertinent medical information on a patient is recorded and accessible to all health care professionals caring for that patient.
C)  It is an approximate record of the patient's condition,illness,and treatment.
D)  To provide a written source of information regarding that patient providing a common source of information for all caregivers. D

Question 18

Information provided to the physician by the patient is _______________________.

Accepted Answer

A)  contained in the progress notes.
B)  always confidential.
C)  objective data.
D)  subjective data

Question 19

Which of the following is NOT true concerning documentation?

Accepted Answer

A)  Document things in anticipation of doing it
B)  The date and time of interaction
C)  Accuracy,timeliness,and truthfulness all are important
D)  Document only what has been performed A

Question 20

When attempting to achieve ventilation goals the respiratory care practitioner should assess the ________________.

Accepted Answer

A)  PaO₂ .
B)  SaO₂ .
C)  PaCO₂ .
D)  HCO₃.

Exam 11: Documentation and Goals Assessment

Upon entering a severe asthmatic's room to deliver bronchodilator therapy,the patient expresses displeasure with his physician and the hospital.What should the practitioner do at this time?

Correct Answer
verified
Effective communication is necessary to ...
View Answer

How are entries entered into the medical record?

Correct Answer
verified

What is a compilation of pertinent facts of a patient's life and health history,illness(es) ,and treatment(s) written by health care professionals who have contributed to the care of that patient?

Correct Answer
verified

Which part of the medical record states the date and time the patient was admitted to the acute care facility as well as the patient's medical diagnosis?

Correct Answer
verified

Which of the following are NOT included in imaging reports?

Correct Answer
verified

How is the history of the patient obtained by the physician?

Correct Answer
verified

Correct Answer
verified

What is the method of charting that usually employs fill-in-the-blank forms where only data that change are documented?

Correct Answer
verified

Which of the following is found in the discharge plan? I.Any prescribed medication II.Teaching for prescribed medication III.Laboratory results

Correct Answer
verified

What are measurable,demonstrated outcomes that can be assessed following patient treatment or intervention?

Correct Answer
verified
A

Which part of the chart contains temperature,pulse,respiration,blood pressure,urine output,oral intake (fluids) ,and daily weights?

Correct Answer
verified

What are measurable outcomes the patient is expected to achieve following the intervention of a health care practitioner?

Correct Answer
verified

Which of the following are recorded in the patient's record? I.Tests II.Treatments III.Procedures IV.Assessments

Correct Answer
verified

Which of the following is NOT true about the patient's medical record?

Correct Answer
verified

Legally,if an event is not documented in the patient's medical record,_______________.

Correct Answer
verified

Correct Answer
verified
The patient's reluctance to hear anymore...
View Answer

What is the purpose of the medical record?

Correct Answer
verified
D

Information provided to the physician by the patient is _______________________.

Correct Answer
verified

Which of the following is NOT true concerning documentation?

Correct Answer
verified
A

When attempting to achieve ventilation goals the respiratory care practitioner should assess the ________________.

Correct Answer
verified

Exam 11: Documentation and Goals Assessment

Upon entering a severe asthmatic's room to deliver bronchodilator therapy,the patient expresses displeasure with his physician and the hospital.What should the practitioner do at this time?

Correct AnswerverifiedEffective communication is necessary to ...View AnswerShow Answer

How are entries entered into the medical record?

Correct AnswerverifiedShow Answer

What is a compilation of pertinent facts of a patient's life and health history,illness(es) ,and treatment(s) written by health care professionals who have contributed to the care of that patient?

Correct AnswerverifiedShow Answer

Which part of the medical record states the date and time the patient was admitted to the acute care facility as well as the patient's medical diagnosis?

Correct AnswerverifiedShow Answer

Which of the following are NOT included in imaging reports?

Correct AnswerverifiedShow Answer

How is the history of the patient obtained by the physician?

Correct AnswerverifiedShow Answer

Correct AnswerverifiedShow Answer

What is the method of charting that usually employs fill-in-the-blank forms where only data that change are documented?

Correct AnswerverifiedShow Answer

Which of the following is found in the discharge plan? I.Any prescribed medication II.Teaching for prescribed medication III.Laboratory results

Correct AnswerverifiedShow Answer

What are measurable,demonstrated outcomes that can be assessed following patient treatment or intervention?

Correct AnswerverifiedA

Which part of the chart contains temperature,pulse,respiration,blood pressure,urine output,oral intake (fluids) ,and daily weights?

Correct AnswerverifiedShow Answer

What are measurable outcomes the patient is expected to achieve following the intervention of a health care practitioner?

Correct AnswerverifiedShow Answer

Which of the following are recorded in the patient's record? I.Tests II.Treatments III.Procedures IV.Assessments

Correct AnswerverifiedShow Answer

Which of the following is NOT true about the patient's medical record?

Correct AnswerverifiedShow Answer

Legally,if an event is not documented in the patient's medical record,_______________.

Correct AnswerverifiedShow Answer

Correct AnswerverifiedThe patient's reluctance to hear anymore...View AnswerShow Answer

What is the purpose of the medical record?

Correct AnswerverifiedD

Information provided to the physician by the patient is _______________________.

Correct AnswerverifiedShow Answer

Which of the following is NOT true concerning documentation?

Correct AnswerverifiedA

When attempting to achieve ventilation goals the respiratory care practitioner should assess the ________________.

Correct AnswerverifiedShow Answer

Correct Answer
verified
Effective communication is necessary to ...
View Answer

Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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A

Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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Correct Answer
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The patient's reluctance to hear anymore...
View Answer

Correct Answer
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D

Correct Answer
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Correct Answer
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A

Correct Answer
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