Wilkins Chapter 21

The patients medical record is a(n):
A. financial document
B. legal document
C. education tool
D. all of the above

What is the primary goal of the Joint Commission?
A. Monitor financial reimbursement of hospitals
B. Provide healthcare workers with a safe work environment.
C. Review healthcare organizations to improve the quality of healthcare and patient safety.
D. Monitor the ethical practice of medicine at healthcare organizations

Which of the following organizations influences what needs to be documented in a patients medical record?
A. The Joint Commission
B. Center for Medicare and Medicaid Services (CMS)
C. Financial intermediaries
D. all of the above.

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.
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 document a procedure performed on a patient

Which of the following conditions is NOT required for the legal definition of negligence?
A. The defendant breached that duty
B. The defendant's breach of duty of care did not cause the plaintiff's injury
C. The plaintiff suffered a legally recognizable injury
D. The defendant owed a duty of care to the plaintiff

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
A. I, II, and IV
B. I, II, III and IV
C. II and IV
D. I, II, and III

The absence of information or lack of documented recognition of specific problems could result in one of the following situations:
A. Reduction in salary for the respiratory therapist
B. Reduction in the workload
C. Malpractice
D. Probation status for the clinician at fault

Which of the following sections of the patient assessment or procedures should be charted immediately?
A. Date and time of test or treatment
B. Result, or response to treatment, including adverse reactions
C. Drugs and their dosages
D. Vital signs

Which of the following words is not consistent with the definition of the SOAP charting method?
A. Physical exam
B. Assesment
C. Subjective
D. Objective

All of the following are examples of "objective" data, except?
A. The patients report of the amount of sputum that he or she produces daily.
B. Laboratory results
C. Observation of a patient's sleep apnea
D. The physicians interpretation of the patient's ECG

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.
A. 90
B. 70
C. 30
D. 50

Which of the following data does NOT constitute part of the objective part of the SOAP charting method?
A. Review of pulmonary function test results
B. Vital signs
C. Review of clinical laboratory data
D. Review of symptoms

What does the letter "I" stand for in the APIE method of documentation?
A. Implementation
B. Idiot
C. Initiative
D. Inconsistencies
E. Impact

Which method of documentation is probably best for a clinician who is pressed for time?
A. SOAP
B. SBAR
C. APIE
D. PIP

Which of the following charting methods has been promoted with implementation of rapid response teams?
A. SBAR
B. SOAP
C. PIP
D. APEI