Chapter 7

1.

1 point

What is the purpose of graphic sheets?
.

To allow readers to see the patient progress at a glance.

To document repetitive actions.

To save documentation time.

To document routine actions.

2.

1 point

When admitting a patient into an outpatient setting, it would be appropriate to include

Chief complaint

Contact information

Allergies

All of the above

3.

1 point

Jurors often state that the most important piece of evidence in malpractice cases is:

Medical record documentation

Expert witness testimony

Physician testimony

Patient and family testimony

4.

1 point

When making a correction in a medical record, you should

Write “error.”

Draw a single line through the mistake.

Remove the page from the chart and rewrite it.

Cross out the error completely.

5.

1 point

Which statement regarding consent forms is not accurate?

They are needed for any invasive procedure.

They should include a statement of the risks and benefits of the procedure.

They should include the fee and agreement to pay for the procedure.

They are needed if you take a photograph of a patient.

6.

1 point

Which statement would be the best one to document?

Big wound and with lots of blood to right leg

Three-inch laceration to right knee

The patient was uncooperative

The patient was agitated and very mean

7.

1 point

If something is not documented in the record, it is considered

An omission

Not important

Not having taken place

none of the above

8.

1 point

Which statement is not written in the active voice?

Dressing changed.

Contacted Dr. White.

Started intravenous line.

Changed dressing.

9.

1 point

Which statement regarding documentation is accurate?

It is best to give a lengthy explanation of events.

Stick to the facts and be specific.

If a colleague made an error, you should imply her incompetence in your documentation to protect yourself.

It is best to save all of your documentation until the end of the day.

10.

1 point

Which statement has a spelling error?

A foul smelling drainage was noted.

Throat culture was obtained.

The physcian was notified.

The urine was cloudy.

11.

1 point

The POMR medical record divides the chart into four parts. Which is not a part?

Progress notes

Database

Problem list

Medication list

12.

1 point

Which statement regarding abbreviations is correct?

They can save time and should be used freely.

It is important that individuals create their own list and follow it.

They can lead to confusion and should only be used according to policy.

They always lead to errors and should not be used.

13.

1 point

Which time is correctly converted into military time?

9:30 p.m. is 22:30

7:10 a.m. is 0720

2:15 p.m. is 1415

7:45 p.m. is 0745

14.

1 point

The “I” in the PIE indicates:

Interview

Instruction

Implementation

Injury

15.

1 point

Telephone triage documentation should include

Name, date and time of the call

Any instructions given to the caller

Follow-up plan along with a time frame

All of the above

16.

1 point

Medical record documentation is important because

It provides legal protection.

It is required for regulatory agencies.

It promotes continuity of patient care.

All the above

17.

1 point

When discharging a patient, it would be appropriate to document

Extent and type of teaching or instruction given.

Follow-up instructions.

Any referrals made for home care assistance.

All of the above.

18.

1 point

An incident report should not be completed for

Drawing blood from the wrong patient

Medication errors

Documenting employee absenteeism

Documenting employee needle stick

19.

1 point

When documenting in the medical record, you should never

Document for someone else

Document false information

Erase, scribble over, or delete documentation

All of the above

20.

1 point

Which is an appropriate “S” in a SOAP note?

“The weather is cold today.”

“My arm hurts.”

"BP 100/82, P 78 and regular

They are all appropriate.