Test Bank for Clinical Manifestations Assessment of Respiratory Disease 6th Edition by Jardins Link full download: http://testbankair.com/download/test-bank-for-clinical-manifestations-assessment-ofrespiratory-disease-6th-edition-by-jardins/ Chapter 10: Recording Skills: The Basis for Data Collection, Organization, Assessment Skills, and Treatment Plans MULTIPLE CHOICE According to the chapter text, which of the following are basic methods to record assessment data? Computer documentation Charting by exception Source-oriented record Problem-oriented medical record a 1,2 b 2, c 1, 3, d 1, 2, 3, ANS: C Widely accepted methods to record patient data include computer documentation, sourceoriented record (also called a traditional chart), and the problem-oriented medical record Charting by exception is not widely used and not presented in the chapter REF: p 155 A patient who had pneumonia, and her family, are suing the hospital, physician, and respiratory therapist How can the patient’s medical care and treatment be proved? a Care is documented in the chart b The patient’s testimony c The physician’s testimony d The respiratory therapist’s testimony ANS: A The patient’s medical chart is a legal document accepted in court While testimony is valuable, people can forget and lie What is documented in the chart is considered to be proof REF: p 155 All of the following blocks of information will be found in a patient’s source-oriented record EXCEPT: a laboratory reports b history c police record d admission information ANS: C If a patient was under police custody, it would be known, but the chart would not include the person’s police record All of the other listed options will be found in a source-oriented record (also called a traditional record) REF: p 155 A problem-oriented medical record is used by health-care practitioners to: systemically gather the patient’s data communicate with the patient’s family develop an assessment formulate a treatment plan a 1, b 3, c 1, 3, d 1, 2, 3, ANS: C A problem-oriented medical record is used to systemically gather the patient’s data, develop an assessment, and formulate a treatment plan Communication will be done by discussion or written materials REF: p 155 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 stands for objective data such as hemodynamic data, blood pressure, sputum production, etc The patient’s admission complaint would be found in the history REF: p 155 When reviewing a SOAPIER progress note, the A stands for: a application of the data b assessment of the data by the patient c affect of the patient d assessment of the data by the health-care worker ANS: D The A stands for assessment of the data by the health-care worker The patient does not assess his/her own data A health-care worker would apply data to the patient’s care plan REF: p 156 When reviewing a SOAPIER progress note, the R stands for: a revisions made in the original plan b refusal of care by the patient c rejection by the physician d resuscitate the patient ANS: A The R stands for revisions that need to be made to the original care plan REF: p 157 Computer-based records are commonly used for which of the following? Retrieving pulmonary function studies 10 Storing treatment information 11 Storing admission data 12 Playing back recorded patient interviews a 3, b 1, c 1, 2, d 1, 2, 3, ANS: C Computer-based records are commonly used for retrieving data such as pulmonary function studies, storing treatment information, storing admission data, and other uses Rarely are patient interviews audio or video recorded REF: p 157 Many respiratory therapists now use portable devices for bedside computer charting These units are referred to as: a point-of-care systems b laptop computers c i-pods d MP3 players ANS: A Point-of-care hand-held computers are used for charting at the bedside Laptop computers may be dedicated for use with a portable pulmonary function testing unit An i-pod is a personal communication device, and an MP3 player is a personal music device REF: p 157 10 Which of the following is a Health Insurance Portability and Accountability Act (HIPAA) rule? a A bank can check for a preexisting condition b The patient controls access to his/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/her medical records Banks and employers are prevented from accessing the patient’s medical information without permission Psychotherapy records are given extra protection REF: pp 157, 160 ... stands for: a application of the data b assessment of the data by the patient c affect of the patient d assessment of the data by the health-care worker ANS: D The A stands for assessment of the... While testimony is valuable, people can forget and lie What is documented in the chart is considered to be proof REF: p 155 All of the following blocks of information will be found in a patient’s... chart b The patient’s testimony c The physician’s testimony d The respiratory therapist’s testimony ANS: A The patient’s medical chart is a legal document accepted in court While testimony is valuable,