Wilkins Chapter 21

  1. The patients medical record is a(n):

    D. all of the above
  2. What is the primary goal of the Joint Commission?

    C. Review healthcare organizations to improve the quality of healthcare and patient safety.
  3. Which of the following organizations influences what needs to be documented in a patients medical record?

    A. The Joint Commission
  4. Which of the following definitions is consistent with negligence?

    A. Failure to use a reasonable amount of care that results in injury or damage to another.
  5. Which of the following conditions is NOT required for the legal definition of negligence?

    B. The defendant's breach of duty of care did NOT cause the plaintiff's injury.
  6. Which of the following outlines the professional standards for respiratory therapists?
    I. AARC clinical practice guidelines
    II. Respiratory care practice act and regulations
    III. Place of employment
    IV. The Joint Commission

    B. I, II, III, and IV
  7. The absence of information or lack of documented recognition of specific problems could result in one of the following situations:

    C. Malpractice
  8. Which of the following sections of the patient assessment or procedures should be charted immediately?

    D. Vital signs
  9. Which of the following words is not consistent with the definition of the SOAP charting method?

    A. Physical exam
  10. All of the following are examples of "objective" data, except?

    A. The patient's report of the amount of sputum that he or she produces daily.
  11. According to experts, obtaining a good medical history from a patient can give you a ____% chance of correctly identifying a patient's problem before you do a single test.

    B. 70%
  12. Which of the following data does NOT constitute part of the objective part of the SOAP charting method?

    D. Review of symptoms
  13. What does the letter "I" stand for in the APIE method of documentation?

    A. Implementation
  14. Which method of documentation is probably best for a clinician who is pressed for time?

    D. PIP
  15. Which of the following charting methods has been promoted with implementation of rapid response teams?

    A. SBAR
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Wilkins Chapter 21
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