MI 116: Unit 2 Study Guide

True or False: Pencil is acceptable to use to write in a patient's chart.

• True

• False

On which part of SBAR can you find the patient's allergies?

• situation

• background

• assessment

• recommendation

Military time is how time should be documented in a patient's chart. How would you document 2 o'clock in the afternoon?

• 200

• 0200

• 1400

• 1300

Who must sign a written consent? (select all that apply)

• patient

• performing physician

• ordering physician

• witness

What must you document every time you make an entry into a chart? (select 3)

• date

• patient's name

• time

• signature

• patient's mrn

Which of the following is the proper way to document and error in a chart?

• A

• B

• C

On which part of SBAR can you find the mobility status of the patient?

• Situation

• Background

• Assessment

• Recommendation

This Act helps to improve efficiency and effectiveness of the health care system by mandating confidentiality of health information.

• HIPPA

• HIPAA

• HPPIA

• IHPAA

Who can write an order for a patient procedure? (select 3)

• MD

• DO

• Nurse

• Nurse practitioner

• Nurse manager

A __________ provides accurate information about a patient's care, treatment, or service when responsibilities are "handed off" from one care provider to another.

• service pass

• communication pass

• transport pass

• hallpass