Recording Skills: The Basis For Data Collection, Organization, Assessment Skill
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- The Patient InterviewThe Physical Examination and Its Basis in PhysiologyPulmonary Function Study AssessmentsArterial Blood Gas AssessmentsOxygenation AssessmentsCardiovascular System AssessmentsRadiologic Examination of the ChestOther Important Tests and ProceduresThe Therapist-Driven Protocol Program and the Role of the Respiratory TherapistRespiratory Failure and the Mechanical Ventilation ProtocolRecording Skills: The Basis for Data Collection, Organization, Assessment SkillChronic Obstructive Pulmonary Disease (COPD), Chronic Bronchitis, and EmphysemaAsthmaBronchiectasisCystic FibrosisPneumoniaLung AbscessTuberculosisFungal Diseases of the LungPulmonary EdemaPulmonary Vascular Disease: Pulmonary Embolism and Pulmonary HypertensionFlail ChestPneumothoraxPleural Effusion and EmpyemaKyphoscoliosisInterstitial Lung DiseasesCancer of the LungAcute Respiratory Distress SyndromeGuillain-Barré SyndromeMyasthenia GravisSleep ApneaClinical Manifestations Common with Newborn and Early Childhood Respiratory DisMeconium Aspiration SyndromeTransient Tachypnea of the NewbornRespiratory Distress SyndromePulmonary Air Leak SyndromesRespiratory Syncytial Virus (Bronchiolitis or Pneumonitis)Bronchopulmonary DysplasiaCongenital Diaphragmatic HerniaCongenital Heart DiseasesCroup Syndrome: Laryngotracheobronchitis and Acute EpiglottitisNear Drowning/Wet DrowningSmoke Inhalation, Thermal Injuries, and Carbon Monoxide IntoxicationAtelectasis
Question 1
Free
Multiple Choice
When reviewing a SOAPIER progress note, all of the following would be found in the O area EXCEPT:
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hemodynamic data.
patient's admission complaint.
blood pressure.
sputum production.
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Question 2
Free
Multiple Choice
When the respiratory therapist is entering a SOAPIER progress note in a patient's chart, the A stands for:
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application of the data.
acceptance of the treatment options by the patient.
affect of the patient.
assessment of the data by the respiratory therapist.
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Question 3
Free
Multiple Choice
When reviewing a SOAPIER progress note, the R stands for:
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revisions made in the original plan.
reimbursement by the insurance carrier.
respiratory care notes.
resuscitation status of the patient.
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Question 4
Free
Multiple Choice
Which of the following statements is TRUE regarding Health Insurance Portability and Accountability Act (HIPAA) regulations?
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A bank can check for a preexisting condition.
The patient controls access to his or her medical records.
Psychotherapy and medical records are treated equally.
An employer can check for a preexisting condition.
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Question 5
Free
Multiple Choice
In which section of the SOAPIER format should the patient's response to a specific treatment modality be recorded?
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Assessment
Implementation
Observation
Evaluation
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Question 6
Multiple Choice
Which agency should be notified if violations of HIPAA regulations have occurred?
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HHS
FDA
CDC
Joint Commission
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Question 7
Multiple Choice
All of the following statements are true regarding a patient's chart EXCEPT:
Choose correct answer/s
the patient's chart is a legal record and can be used in court.
accreditation agencies may access a patient's chart to assess appropriateness of care.
the patient's insurance company may review the patient's chart before providing reimbursement.
the patient's spouse may access the patient's chart without authorization by the patient.
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