Clinical Manifestations And Assessment 7th Edition Of Respiratory Disease By Terry – Test Bank

Chapter 11: Recording Skills: The Basis for Data Collection, Organization, Assessment Skill
Des Jardins: Clinical Manifestations and Assessment of Respiratory Disease, 7th Edition

MULTIPLE CHOICE

1. Which of the following are basic methods to record assessment data?
1. Computer documentation
2. Block chart
3. Source-oriented record
4. 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), block chart, and problem-oriented medical record.

REF: p. 163

2. A problem-oriented medical record is used by health-care practitioners to:
1. systemically gather the patient’s data.
2. communicate with the patient’s family.
3. develop an assessment.
4. 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.

REF: p. 163

3. 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 in SOAPIER stands for objective information and would include hemodynamic data, vital signs, and sputum production. The patient’s admission complaint would not be recorded in the objective data but would be located on the admission note or history section of the medical record.

REF: p. 163

4. When the respiratory therapist is entering a SOAPIER progress note in a patient’s chart, the A stands for:
a. application of the data.
b. acceptance of the treatment options by the patient.
c. affect of the patient.
d. assessment of the data by the respiratory therapist.

ANS: D
The A represents assessment of the data. The respiratory therapist would assess the patient’s subjective and objective data to identify the cause of their condition.

REF: p. 163

5. When reviewing a SOAPIER progress note, the R stands for:
a. revisions made in the original plan.
b. reimbursement by the insurance carrier.
c. respiratory care notes.
d. resuscitation status of the patient.

ANS: A
The R stands for revisions that need to be made to the original care plan. The treatment plan may require modification or treatment modalities may need to be up-regulated or down-regulated.

REF: p. 163

6. Computer-based records are commonly used for which of the following?
1. Retrieving pulmonary function studies
2. Storing treatment information
3. Storing admission data
4. Ordering patient supplies
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 ordering patient supplies. Electronic health records are now the standard in most care settings.

REF: p. 166

7. Which of the following statements is TRUE regarding Health Insurance Portability and Accountability Act (HIPAA) regulations?
a. A bank can check for a preexisting condition.
b. The patient controls access to his or 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 or her medical records. Banks and employers are prevented from accessing the patient’s medical information without permission. Psychotherapy records are given extra protection.

REF: p. 167

8. In which section of the SOAPIER format should the patient’s response to a specific treatment modality be recorded?
a. Assessment
b. Implementation
c. Observation
d. Evaluation

ANS: D
Measurable data regarding the effectiveness of a therapy plan and the patient’s response to the treatment would be recorded under “E”—evaluation.

REF: p. 163

9. Which agency should be notified if violations of HIPAA regulations have occurred?
a. HHS
b. FDA
c. CDC
d. Joint Commission

ANS: A
Alleged breaches of HIPAA regulations should be reported to the U.S. Department of Health and Human Services (HHS). Privacy breaches may be subject to civil and criminal action. Significant fines may be imposed for proven violations.

REF: p. 167

10. All of the following statements are true regarding a patient’s chart EXCEPT:
a. the patient’s chart is a legal record and can be used in court.
b. accreditation agencies may access a patient’s chart to assess appropriateness of care.
c. the patient’s insurance company may review the patient’s chart before providing reimbursement.
d. the patient’s spouse may access the patient’s chart without authorization by the patient.

ANS: D
While patients can expect a certain degree of privacy surrounding medical records, patient charts may be accessed under specific circumstances by select agencies for accreditation reviews, reimbursement claims, and legal cases. The patient controls his or her privacy, and unless a documented release has been granted, a spouse would be denied access to information in the chart.

REF: p. 162