Test bank for clinical manifestations assessment of respiratory disease 6th edition by jardins

According to the chapter text, which of the following are basic methods to record assessment data?. Widely accepted methods to record patient data include computer documentation, source-

Test Bank for Clinical Manifestations Assessment of Respiratory Disease 6th Edition by Jardins

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Chapter 10: Recording Skills: The Basis for Data Collection, Organization,

Assessment Skills, and Treatment Plans

MULTIPLE CHOICE

1 According to the chapter text, which of the following are basic methods to record

assessment data?

2 Computer documentation

3 Charting by exception

4 Source-oriented record

5 Problem-oriented medical record

a 1,2

b 2, 3

c 1, 3, 4

d 1, 2, 3, 4

ANS: C

Widely accepted methods to record patient data include computer documentation, source- oriented record (also called a traditional chart), and the problem-oriented medical record Charting by exception is not widely used and not presented in the chapter

2 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 Care is documented in the chart

b The patient’s testimony

c The physician’s testimony

d The respiratory therapist’s testimony

ANS: A

The patient’s medical chart is a legal document accepted in court While testimony is valuable, people can forget and lie What is documented in the chart is considered to be proof

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

a laboratory reports

b history

c police record

d admission information

ANS: C

If a patient was under police custody, it would be known, but the chart would not include the person’s police record All of the other listed options will be found in a source-oriented record (also called a traditional record)

REF: p 155

4 A problem-oriented medical record is used by health-care practitioners to:

5 systemically gather the patient’s data

6 communicate with the patient’s family

7 develop an assessment

8 formulate a treatment plan

a 1, 2

b 3, 4

c 1, 3, 4

d 1, 2, 3, 4

ANS: C

A problem-oriented medical record is used to systemically gather the patient’s data, develop an assessment, and formulate a treatment plan Communication will be done by discussion or written materials

5 When reviewing a SOAPIER progress note, all of the following would be found

In the O area EXCEPT:

a hemodynamic data

b patient’s admission complaint

c blood pressure

d sputum production

ANS: B

The O stands for objective data such as hemodynamic data, blood pressure, sputum production, etc The patient’s admission complaint would be found in the history

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

a application of the data

b assessment of the data by the patient

c affect of the patient

d assessment of the data by the health-care worker

ANS: D

The A stands for assessment of the data by the health-care worker The patient does not assess his/her own data A health-care worker would apply data to the patient’s care plan

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

a revisions made in the original plan

b refusal of care by the patient

c rejection by the physician

d resuscitate the patient

ANS: A

The R stands for revisions that need to be made to the original care plan

8 Computer-based records are commonly used for which of the following?

9 Retrieving pulmonary function studies

10 Storing treatment information

11 Storing admission data

12 Playing back recorded patient interviews

a 3, 4

b 1, 2

c 1, 2, 3

d 1, 2, 3, 4

ANS: C

Computer-based records are commonly used for retrieving data such as pulmonary function studies, storing treatment information, storing admission data, and other uses Rarely are patient interviews audio or video recorded

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

a point-of-care systems

b laptop computers

c i-pods

d MP3 players

ANS: A

Point-of-care hand-held computers are used for charting at the bedside Laptop computers may be dedicated for use with a portable pulmonary function testing unit An i-pod is a personal communication device, and an MP3 player is a personal music device

10 Which of the following is a Health Insurance Portability and Accountability

Act

(HIPAA) rule?

a A bank can check for a preexisting condition

b The patient controls access to his/her medical records

c Psychotherapy and medical records are treated equally

d An employer can check for a preexisting condition

ANS: B

With the HIPAA, the patient controls access to his/her medical records Banks and employers are prevented from accessing the patient’s medical information without permission Psychotherapy records are given extra protection