Question

1. if a patient reports feelings to you, you should ______.

a. not document them as they are too subjective.
b. document them.
c. talk them over with your supervisor before documenting them.
d. report them immediately to the physician.

1. an unusual occurrence report is ______.

a. a record of abnormal vital signs.
b. a daily record of sudden increases in pain level.
c. a record of any unusual incident or problem.
d. a record of unusual visitors to the patient.

1. all information about a patient is confidential unless he authorizes the release or ______.

a. the family authorizes release.
b. the physician authorizes release.
c. the billing department authorizes release.
d. the law requires release.

1. the hipaa act covers confidentiality of medical information ______.

a. only on the physical chart.
b. in all forms, including electronic.
c. only within the hospital.
d. only between the hospital and insurance carriers.

1. all of the instances below represent reportable exceptions to confidentiality, except ______.

a. child abuse.
b. industrial accidents.
c. car accidents.
d. deaths of an uncertain nature.

1. when you are finished with an electronic charting record, you should ______.

a. leave the computer signed on for later entries.
b. turn the monitor away from busy areas when you leave it.
c. delete the record.
d. sign off.

1. the record \temperature normal\ would be considered:

a. too generalized.
b. entirely accurate.
c. subjective.
d. misspelled.

Explanation:

Question 7

In healthcare documentation, patient feelings (subjective data) are important to document as they provide context about the patient's experience. Option a is wrong as subjective data is documented. Option c is unnecessary; feelings can be documented without supervisor discussion first. Option d is incorrect as reporting to a physician isn't needed for just reporting feelings—documentation is the first step. So option b is correct.

An unusual occurrence report (also called an incident report) is for recording any unusual incident or problem in a healthcare setting. Option a is about vital signs (part of regular charting), option b is daily pain (regular assessment), option d is about visitors (not an "occurrence" in the incident - report sense). So option c matches the definition.

Patient confidentiality is protected unless the patient authorizes release or the law requires it (e.g., court orders, mandatory reporting situations). Family or physician authorization isn't a standard exception unless the law or patient allows. The billing department has no authority to override confidentiality. So option d is correct.

Answer:

b. Document them.

Question 8