The patients medical record is a(n):
A. financial document
B. legal document
C. education tool
D. all of the above
D. all of the above
What is the primary goal of the Joint Commission?
A. Provide healthcare workers with a safe work environment.
B. Monitor financial reimbursement of hospitals
C. Review healthcare organizations to improve the quality of healthcare and patient safety.
D. Monitor the ethical practice of medicine at healthcare organizations
C. Review healthcare organizations to improve the quality of healthcare and patient safety.
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.
A. The Joint Commission
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 obtain a license to practice despite good clinical performance
C. Failure to document a procedure performed on a patient
D. Failure to explain to a patient the purpose of a therapy
A. Failure to use a reasonable amount of care that results in injury or damage to another.
Which of the following conditions is NOT required for the legal definition of negligence?
A. The defendant breached that duty
B. The defendant owed a duty of care to the plaintiff
C. The defendant's breach of duty of care did not cause the plaintiff's injury
D. The plaintiff suffered a legally recognizable injury
C. The defendant's breach of duty of care did NOT cause the plaintiff's injury.
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
B. I, II, III, and IV
The absence of information or lack of documented recognition of specific problems could result in one of the following situations:
A. Probation status for the clinician at fault
B. Reduction in salary for the respiratory therapist
C. Malpractice
D. Reduction in the workload
C. Malpractice
Which of the following sections of the patient assessment or procedures should be charted immediately?
A. Drugs and their dosages
B. Vital signs
C. Result, or response to treatment, including adverse reactions
D. Date and time of test or treatment
B. Vital signs
Which of the following words is not consistent with the definition of the SOAP charting method?
A. Assesment
B. Physical exam
C. Objective
D. Subjective
B. Physical exam
All of the following are examples of "objective" data, except?
A. Laboratory results
B. The patients report of the amount of sputum that he or she produces daily.
C. Observation of a patient's sleep apnea
D. The physicians interpretation of the patient's ECG
B. The patient's report of the amount of sputum that he or she produces daily.
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. 50
D. 30
B. 70%
Which of the following data does NOT constitute part of the objective part of the SOAP charting method?
A. Vital signs
B. Review of clinical laboratory data
C. Review of pulmonary function test results
D. Review of symptoms
D. Review of symptoms
What does the letter "I" stand for in the APIE method of documentation?
A. Idiot
B. Initiative
C. Inconsistencies
D. Impact
E. Implementation
E. Implementation
Which method of documentation is probably best for a clinician who is pressed for time?
A. PIP
B. APIE
C. SBAR
D. SOAP
A. PIP
Which of the following charting methods has been promoted with implementation of rapid response teams?
A. PIP
B. APEI
C. SBAR
D. SOAP
C. SBAR