Documentation Test – Correct Care, Inc.

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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)

True

False

2. The majority of malpractice claims involve patients who were sent home from the ED and suffered a complication. (True / False - 10 Points)

True

False

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)

True

False

4. It is easy to defend a physician who ignores abnormal test results that he/she ordered. (True / False - 10 Points)

True

False

5. Failure to consult is one of the Ten Most Common Areas for Medical Malpractice in the E.D. (True / False - 10 Points)

True

False

6. The importance of the medical record cannot be understated: The medical record: (Multiple Choice - 10 Points)

Provides communication regarding what exactly was done for each patient by each member of the team this is paramount to patient safety

Forms the basis from which medical malpractice cases are developed

Justifies patient billing

All of the above

7. If the decision is made not to admit; the discharge instructions should always include the following: (Multiple Choice - 10 Points)

Who to follow up with

When to follow up

Expected course Specific reasons to return to the E.D

All of the above

8. This concept forms the basis of almost all negligence claims. (Multiple Choice - 10 Points)

Lack of Communication

Wrong Diagnosis

Improper Use of Medical Equipment

Improper Prescribing of Medications

9. If You Make an Error in Charting; you should: (Multiple Choice - 10 Points)

Make a single line through the error; followed by your initial; date and time

Discard the entire chart and begin again

Erase the error and write over in the same space

Completely blacken the error so that it cannot be seen

10. Emergency Department nursing notes are rarely IRRELEVANT. (True / False - 10 Points)

True

False

11. One of the greatest legal defenses a physician has is to document properly. (True / False - 10 Points)

True

False

12. Some of the components which are used in defining the levels of evaluation and management services are: (Multiple Choice - 10 Points)

History and examination

Medical decision making

Counseling and Coordination of Care

All of the above

13. The four types of examinations are problem focused; expanded problem focused; detailed and comprehensive. (True / False - 10 Points)

True

False

14. Some of the key elements of the medical record include: (Multiple Choice - 10 Points)

Chief complaint

Review of systems

History of present illness

All of the above

15. The medical record documentation is required to record relevant facts; findings and observations about a patient's history. (True / False - 10 Points)

True

False

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)

True

False

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)

True

False

18. For purposes of examination; some of the body areas that are recognized include: (Multiple Choice - 10 Points)

Abdomen and back

Head and face

Neck and chest

All of the above

19. The HPI is a chronological description of the development of the patient's present illness. (True / False - 10 Points)

True

False

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)

True

False

21. Content of this activity was free of commercial bias? (Answer not graded- Survey Question)

True

False

22. Presentation level and content was appropriate? (Answer not graded- Survey Question)

True

False

23. Your educational needs were satisfied, and you will apply what you have learned in your practice? (Answer not graded- Survey Question)

True

False

24. Educational design and format was clear and easy to understand? (Answer not graded- Survey Question)

True

False

25. Stated objectives were clearly presented and met? (Answer not graded- Survey Question)

True

False

How will you apply what you have learned to your practice? *