Chapter 21: Documentation

MULTIPLE CHOICE

1. The patient’s medical record is a/an:

a.
financial document.
b.
legal document.
c.
educational tool.
d.
all of the above.

ANS: D

The reasons for creating a record of the patient’s interactions with any healthcare organization (HCO) include the following:

· To create a legal record of care and service provided;

· To collect evidence in support of the patient’s problems and needs (when the clinical facts about the patient’s condition are collected, the correct diagnosis can be confirmed and the patient’s clinical progress can be better documented);

· To provide communication between members of the healthcare team;

· To support appropriate reimbursement;

· To support the operation of the HCO and its allocation of internal resources and to provide documentation of compliance with The Joint Commission and regulatory standards of care; and

· To prepare an educational tool.

REF: pg. 470 OBJ: 1

2. What is the primary goal of The Joint Commission?

a.
Monitor financial reimbursement of hospitals
b.
Review healthcare organizations to improve the quality of healthcare and patient safety
c.
Provide healthcare workers with a safe work environment
d.
Monitor the ethical practice of medicine at healthcare organizations

ANS: B

The Joint Commission performs an on-site survey of HCOs so as to assess the quality of patient care and to improve patient safety.

REF: pg. 471 OBJ: 2

3. Which of the following organizations influences what needs to be documented in a patient’s medical record?

a.
The Joint Commission
b.
Center for Medicare and Medicaid Services (CMS)
c.
Financial intermediaries
d.
All of the above

ANS: A

The Joint Commission surveyors review patient records for documentation of high-quality patient care.

REF: pg. 471 OBJ: 2

4. Which of the following definitions is consistent with negligence?

a.
Failure to document a procedure performed on a patient
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 use a reasonable amount of care that results in injury or damage to another

ANS: D

Negligence is defined as an instance of failure to use a reasonable amount of care (ordinary prudence) that results in injury or damage to another.

REF: pg. 472 OBJ: 3

5. Which of the following conditions is not required for the legal definition of negligence?

a.
The defendant owed a duty of care to the plaintiff.
b.
The defendant breached that duty.
c.
The plaintiff suffered a legally recognizable injury.
d.
The defendant’s breach of duty of care did not cause the plaintiff’s injury.

ANS: D

Generally, the legal definition of negligence requires the presence of the following four conditions:

· The defendant owed a duty of care to the plaintiff;

· The defendant breached that duty;

· The plaintiff suffered a legally recognizable injury; and

· The defendant’s breach of duty of care caused the plaintiff’s injury.

REF: pg. 472 OBJ: 3

6. Which of the following outlines the professional standards for respiratory therapists (RTs)?

1. American Association for Respiratory Care (AARC) clinical practice guidelines

2. Respiratory care practice act and regulations

3. Place of employment

4. The Joint Commission

a.
1, 2, and 4
b.
1, 2, and 3
c.
1, 2, 3, and 4
d.
2 and 4

ANS: C

The scope of your duty to a patient is outlined by your professional standard (e.g., the AARC clinical practice guidelines, your state’s respiratory care practice act and regulations, and The Joint Commission standards). Your scope of practice is defined further, or is limited, by your job description at your place of employment.

REF: pg. 472 OBJ: 3

7. The absence of information or the lack of documented recognition of specific problems could result in which one of the following situations?

a.
Malpractice
b.
Reduction in salary for an RT
c.
Reduction in workload
d.
Probation status for the clinician at fault

ANS: A

The absence of information or the lack of documented recognition of specific problems could constitute malpractice.

REF: pg. 472 OBJ: 3

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

a.
Date and time of test or treatment
b.
Vital signs
c.
Result of or response to treatment, including adverse reactions
d.
Drugs and their dosages

ANS: B

Vital signs and parameters should be charted immediately. Late entries of clinical notes or observations should be marked clearly as late entries and should show the time entered and the time or period covered in the note.

REF: pg. 473 OBJ: 4

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

a.
Subjective
b.
Objective
c.
Assessment
d.
Physical examination

ANS: D

One of the most frequently used methods of documenting patient assessments is the SOAP (subjective, objective, assessment, and plan) charting method.

REF: pg. 474 OBJ: 5

10. All of the following are examples of “objective” data, except:

a.
laboratory results.
b.
observation of a patient’s sleep apnea.
c.
the patient’s report of the amount of sputum that he or she produces daily.
d.
the physician’s interpretation of the patient’s electrocardiogram (ECG).

ANS: C

Subjective information is what the patient can tell you about how he or she feels.

REF: pg. 474 OBJ: 5

11. According to experts, obtaining a good _____________ from a patient can give you a reasonable chance of correctly identifying a patient’s problem before you do a single test.

a.
arterial blood gas (ABG) results
b.
chief complaint
c.
medical history
d.
appearance

ANS: C

According to experts, obtaining a good medical history from a patient can give you a reasonable chance of correctly identifying a patient’s problem before you do a single test.

REF: pg. 474 OBJ: 5

12. Which of the following data do not constitute part of the objective information section in the SOAP charting method?

a.
Vital signs
b.
Review of systems
c.
Review of clinical laboratory data
d.
Review of pulmonary function test results

ANS: B

The O in SOAP stands for “objective.” This is everything you see, hear, feel, smell, and learn from tests and procedures. This section of the data collection can include the following:

· Vital signs;

· Physical examination information about the head and neck, abdomen, and extremities, to look for physical evidence of a respiratory abnormality;

· Physical examination information about the thorax (heart and lungs) obtained by inspection, palpation, percussion, and auscultation (see Chapter 5);

· Review of clinical laboratory studies (see Chapter 7);

· Review of arterial blood gases (see Chapter 8);

· Review of pulmonary function tests (see Chapter 9);

· Review of radiologic procedures, such as chest radiographs, computed tomograms, and magnetic resonance images (see Chapter 10);

· Review of electrocardiograms (ECGs) (see Chapter 11);

· Review of intensive care unit (ICU) hemodynamic data and cardiac outputs (see Chapters 15 and 16); and

· Review of respiratory mechanics monitoring (see Chapter 14).

REF: pg. 474 OBJ: 5

13. What does the letter I stand for in the APIE method of documentation?

a.
Implementation
b.
Impact
c.
Inconsistencies
d.
Initiative

ANS: A

Primary goals of the assessment, plan, implementation, and evaluation (APIE) method are to condense data collection statements and to emphasize evaluation of the effectiveness of the interventions.

REF: pg. 477 OBJ: 6

14. Which of the following methods of documentation is probably best for a clinician who is pressed for time?

a.
SOAP
b.
APIE
c.
PIP
d.
SBAR

ANS: C

The PIP method works well for the experienced clinician who is pressed for time, wants to meet charting requirements, and needs to be brief.

REF: pg. 477 OBJ: 6

15. Which of the following charting methods has been promoted with implementation of rapid response teams (RRTs)?

a.
PIP
b.
SOAP
c.
SBAR
d.
APIE

ANS: C

The SBAR method has proven highly successful in critical situations and has been promoted with the implementation of RRTs. It is most successful in documenting summary information, including fewer than five key points. It is not as effective for broad communication and context.

REF: pg. 477 OBJ: 7

16. The major purpose of the electronic medical record (EMR) includes which of the following?

a.
Increase efficiencies in the healthcare system
b.
Improve the quality of patient care
c.
Increase patient safety
d.
All of the above

ANS: D

The EMR stands to increase efficiencies in the healthcare system and improve the quality of care and patient safety.

REF: pg. 473 OBJ: 8

17. All of the following are advantages of the EMR except:

a.
lack of standardization among systems.
b.
increased storage capacity.
c.
information is concurrently available even at remote sites.
d.
increased accuracy.

ANS: A

The advantages of the EMR include the following:

· Legibility;

· Increased storage capacity for longer periods of time;

· Accessibility from remote sites;

· Information that is concurrently available;

· Built-in “alert” systems for critical tests and values;

· Customized views for various users;

· Increased management monitoring capabilities; and

· Increased accuracy.

The disadvantages of the EMR include the following:

· High start-up and maintenance costs;