Documentation Test

1. Failure to take an adequate history is one of the Ten Most Common Areas for Medical Malpractice in the E.D. (True / False - 10 Points)
2. The majority of malpractice claims involve patients who were sent home from the ED and suffered a complication. (True / False - 10 Points)
3. Failure to perform adequate exam is one of the Ten Most Common Areas for Medical Malpractice in the E.D. (True / False - 10 Points)
4. It is easy to defend a physician who ignores abnormal test results that he/she ordered. (True / False - 10 Points)
5. Failure to consult is one of the Ten Most Common Areas for Medical Malpractice in the E.D. (True / False - 10 Points)
6. The importance of the medical record cannot be understated: The medical record: (Multiple Choice - 10 Points)
7. If the decision is made not to admit; the discharge instructions should always include the following: (Multiple Choice - 10 Points)
8. This concept forms the basis of almost all negligence claims. (Multiple Choice - 10 Points)
9. If You Make an Error in Charting; you should: (Multiple Choice - 10 Points)
10. Emergency Department nursing notes are rarely IRRELEVANT. (True / False - 10 Points)
11. One of the greatest legal defenses a physician has is to document properly. (True / False - 10 Points)
12. Some of the components which are used in defining the levels of evaluation and management services are: (Multiple Choice - 10 Points)
13. The four types of examinations are problem focused; expanded problem focused; detailed and comprehensive. (True / False - 10 Points)
14. Some of the key elements of the medical record include: (Multiple Choice - 10 Points)
15. The medical record documentation is required to record relevant facts; findings and observations about a patient's history. (True / False - 10 Points)
16. The ER physician's responsibility is to document the patient's encounter - they are not required to include the rationale for the tests they order. (True / False - 10 Points)
17. When discussing the types of examinations; a detailed examination includes a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). (True / False - 10 Points)
18. For purposes of examination; some of the body areas that are recognized include: (Multiple Choice - 10 Points)
19. The HPI is a chronological description of the development of the patient's present illness. (True / False - 10 Points)
20. If a medical malpractice suit is possible; it is important to obtain the medical records immediately and correct or change any orders or notes that might cause you a problem in court. (True / False - 10 Points)
21. Content of this activity was free of commercial bias? (Answer not graded- Survey Question)
22. Presentation level and content was appropriate? (Answer not graded- Survey Question)
23. Your educational needs were satisfied, and you will apply what you have learned in your practice? (Answer not graded- Survey Question)
24. Educational design and format was clear and easy to understand? (Answer not graded- Survey Question)
25. Stated objectives were clearly presented and met? (Answer not graded- Survey Question)