:TYPE:MC:1:0:C
:TITLE:Question TF #1
:QUESTION:H
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Medical records are legal documents that can be used as legal evidence in court.</div>
:LAYOUT:vertical
:ANSWER1:100:H
True
:REASON1:H
Correct.
:ANSWER2:0:H
False
:REASON2:H
Incorrect.
:FEEDBACK
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Medical records are legal documents.</div>
:CAT:Mitchell_Examviewch19

:TYPE:MC:1:0:C
:TITLE:Question TF #2
:QUESTION:H
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>A good way for health care workers to increase their efficiency is to gather all the records for patients to be seen that day and prepare the written documentation in advance for procedures to be done during the day.</div>
:LAYOUT:vertical
:ANSWER1:0:H
True
:REASON1:H
Incorrect.
:ANSWER2:100:H
False
:REASON2:H
Correct.
:FEEDBACK
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Advance charting can result in procedures not being done if circumstances change.</div>
:CAT:Mitchell_Examviewch19

:TYPE:MC:1:0:C
:TITLE:Question TF #3
:QUESTION:H
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Medical charting should be done in pencil because mistakes can be more easily and neatly corrected.</div>
:LAYOUT:vertical
:ANSWER1:0:H
True
:REASON1:H
Incorrect.
:ANSWER2:100:H
False
:REASON2:H
Correct.
:FEEDBACK
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Charting must always be done in ink and any corrections must be legible.</div>
:CAT:Mitchell_Examviewch19

:TYPE:MC:1:0:C
:TITLE:Question TF #4
:QUESTION:H
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Incomplete documentation can result in denial of payment to health providers by insurance companies.</div>
:LAYOUT:vertical
:ANSWER1:100:H
True
:REASON1:H
Correct.
:ANSWER2:0:H
False
:REASON2:H
Incorrect.
:FEEDBACK
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>If it is not correctly documented, the insurance company assumes it was not done.</div>
:CAT:Mitchell_Examviewch19

:TYPE:MC:1:0:C
:TITLE:Question MC #1
:QUESTION:H
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Which is the correct way to document a patient&#8217;s statement about symptoms experienced?</div>
:LAYOUT:vertical
:ANSWER1:100:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Write direct quotes and enclose the entry in quotation marks.</span>
:REASON1:T
Correct.
:ANSWER2:0:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Write the statement in your own words.</span>
:REASON2:T
Using a direct quote is more accurate.
:ANSWER3:0:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Note the statement in a shortened form, using standard abbreviations.</span>
:REASON3:T
Using the full direct quote is more accurate.
:ANSWER4:0:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>List the symptoms, using correct medical terminology.</span>
:REASON4:T
Using a direct quote is more accurate.
:CAT:Mitchell_Examviewch19

:TYPE:MC:1:0:C
:TITLE:Question MC #2
:QUESTION:H
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>How should the health care worker select appropriate abbreviations to use in written documentation?</div>
:LAYOUT:vertical
:ANSWER1:0:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Create personal abbreviations that are clear.</span>
:REASON1:T
Only facility-approved abbreviations may be used.
:ANSWER2:0:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Refer to a standard medical dictionary.</span>
:REASON2:T
Only facility-approved abbreviations may be used.
:ANSWER3:0:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Use those learned in medical terminology courses.</span>
:REASON3:T
Only facility-approved abbreviations may be used.
:ANSWER4:100:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Follow facility policies.</span>
:REASON4:T
Correct
:CAT:Mitchell_Examviewch19

:TYPE:MC:1:0:C
:TITLE:Question MC #3
:QUESTION:H
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>What is the best way to record in a patient&#8217;s report that he only slept from about 1&#058;00 a.m. to 4&#058;30 a.m.?</div>
:LAYOUT:vertical
:ANSWER1:0:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Patient reports difficulty sleeping.</span>
:REASON1:T
This is not specific.
:ANSWER2:0:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Patient is sleeping poorly.</span>
:REASON2:T
This is not specific.
:ANSWER3:100:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Patient states, &#8220;I only slept 3 1/2 hours last night.&#8221;</span>
:REASON3:T
Correct.
:ANSWER4:0:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Patient needs help sleeping.</span>
:REASON4:T
This is a conclusion, not a specific reference to what the patient said.
:CAT:Mitchell_Examviewch19

:TYPE:MC:1:0:C
:TITLE:Question MC #4
:QUESTION:H
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>A coworker calls from home and asks you to sign his name on a patient chart that he forgot to sign after administering a medication. What should you do?</div>
:LAYOUT:vertical
:ANSWER1:0:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Sign his name.</span>
:REASON1:T
It is illegal to sign someones signature.
:ANSWER2:0:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Sign your name.</span>
:REASON2:T
It is illegal to sign your name on a medication you did not give.
:ANSWER3:0:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Sign both your names.</span>
:REASON3:T
It is never appropriate to sign someone elses name.
:ANSWER4:100:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Refuse to sign either name.</span>
:REASON4:T
Correct.
:CAT:Mitchell_Examviewch19

:TYPE:MC:1:0:C
:TITLE:Question MC #5
:QUESTION:H
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Which method of organization describes the source-oriented approach to medical recordkeeping?</div>
:LAYOUT:vertical
:ANSWER1:0:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>chronological order</span>
:REASON1:T
All forms of charting follow a chronological format.
:ANSWER2:100:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>by health care specialty</span>
:REASON2:T
Correct.
:ANSWER3:0:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>by the type of health problem</span>
:REASON3:T
SOAP notes are organized by health problem.
:ANSWER4:0:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>by the body system affected</span>
:REASON4:T
This is not a specific charting organization format.
:CAT:Mitchell_Examviewch19

:TYPE:MC:1:0:C
:TITLE:Question MC #6
:QUESTION:H
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Which of the following personnel may write progress notes that are included in the patient&#8217;s official medical record?</div>
:LAYOUT:vertical
:ANSWER1:0:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>only physicians</span>
:REASON1:T
Charting is not done only by physicians.
:ANSWER2:0:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>only nurses</span>
:REASON2:T
Charting is not done only by nurses.
:ANSWER3:0:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>only physicians and nurses</span>
:REASON3:T
Charting is not done only by physicians and nurses.
:ANSWER4:100:H
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>any health care worker who provides a direct service to the patient</span>
:REASON4:T
Correct.
:CAT:Mitchell_Examviewch19

:TYPE:M:long:long:E:1
:TITLE:Question MA #1-5
:QUESTION:H
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'><i>Match each term with the correct definition below.</i></div>
:L1
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Collection of documents that forms the complete health history of a patient</span>
:R1
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Medical record</span>
:L2
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Reason the patient seeks medical care</span>
:R2
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Chief complaint</span>
:L3
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>All notes added to a patient&#8217;s medical record</span>
:R3
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Medical documentation</span>
:L4
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Recording observations and information about patients</span>
:R4
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Charting</span>
:L5
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Opinions of a health care professional about the nature of the patient&#8217;s problem</span>
:R5
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Assessment</span>
:CAT:Mitchell_Examviewch19

:TYPE:M:long:long:E:1
:TITLE:Question MA #6-10
:QUESTION:H
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'><i>Match each section of the medical record with the correct sample contents below.</i></div>
:L1
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Chronological record of care administered</span>
:R1
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Progress notes</span>
:L2
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Complete personal, familial, and social information</span>
:R2
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Medical history</span>
:L3
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>X-rays, EKG reports, results of blood tests</span>
:R3
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Diagnostic tests</span>
:L4
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Visual format for recording measurements such as blood pressure</span>
:R4
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Graphics</span>
:L5
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Medications and treatments that have been prescribed</span>
:R5
<span style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Physician&#8217;s orders</span>
:CAT:Mitchell_Examviewch19

:TYPE:S
:TITLE:Question CO #1
:QUESTION:H
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Every entry on a medical record must include the ____________________ and ____________________ and the ____________________ of the health care worker who made the entry.</div>
:ANSWERS:1
:CASE:0
:ANSWER1:time; date; signature:100:0:60:0
:CAT:Mitchell_Examviewch19

:TYPE:S
:TITLE:Question CO #2
:QUESTION:H
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Medical documentation that is not ____________________ is useless and may cause legal problems.</div>
:ANSWERS:1
:CASE:0
:ANSWER1:legible:100:0:60:0
:ANSWER2:easy to read:100:0:60:0
:ANSWER3:clear:100:0:60:0
:CAT:Mitchell_Examviewch19

:TYPE:S
:TITLE:Question CO #3
:QUESTION:H
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>When using the method known as &#8220;charting by exception,&#8221; only _________________________ are noted.</div>
:ANSWERS:1
:CASE:0
:ANSWER1:abnormal findings:100:0:60:0
:ANSWER2:abnormal results:100:0:60:0
:CAT:Mitchell_Examviewch19

:TYPE:P
:TITLE:Question SA #1
:QUESTION:H:60:5
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>List at least eight characteristics of good medical documentation.</div>
:ANSWER:H
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Complete; concise and factual; properly identified; legible; uses correct spelling, punctuation, and grammar; accurate; without unnecessary duplications; uses only approved abbreviations; all entries have time and date; all entries are properly signed; no empty lines between entries; always completed after the procedure is done or medication administered; written in blue or black ink; corrections made properly per facility policy</div>
:CAT:Mitchell_Examviewch19

:TYPE:P
:TITLE:Question SA #2
:QUESTION:H:60:5
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>List the four steps required when correcting an error made on a medical record.</div>
:ANSWER:H
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>1. draw a single line through the error<br>2. write in the correct information near the original entry<br>3. note the error as required by facility<br>4. date and initial the correction</div>
:CAT:Mitchell_Examviewch19

:TYPE:P
:TITLE:Question SA #3
:QUESTION:H:60:5
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>List the four components of problem-oriented charting as outlined by the acronym SOAP.</div>
:ANSWER:H
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Subjective data (reported by patient, symptoms), objective data (observed or measured by health care personnel, signs), assessment (health care professional&#8217;s opinion of patient&#8217;s problem), and plan (procedures, treatments, and instructions)</div>
:CAT:Mitchell_Examviewch19

:TYPE:P
:TITLE:Question ES #1
:QUESTION:H:60:5
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Discuss the meaning of the phrase &#8220;If it isn't documented, it isn&#8217;t done.&#8221; Include in your answer a discussion of the possible consequences of incomplete or missing documentation.</div>
:ANSWER:H
<div style='font-size:12pt; font-family:"Times New Roman"; color:#000000;'>Written documentation is the only proof of health care actions; provides means of communication among health care professionals; ensures consistency of care. Negative consequences include lack of proof in case of lawsuit, noncompliance with regulatory agencies, denial of insurance claims, duplication of resources, and a lack of preventive measures.</div>
:CAT:Mitchell_Examviewch19

