UNIT 13. OBSERVATION AND CHARTING
Which of the following most completely defines observation?
A. Watching the activities of the resident
B. Listening to the resident and to staff reports
C. Reading the charts and records
D. Gathering resident information by using the four main senses - answerD
An error made with while writing the resident's chart is corrected by
A. Crossing out the mistake until it can no longer be read
B. Tearing out the sheet and writing on a new one
C. Drawing a line through the wrong entry and explaining why it was an error
D. Drawing a single line through the entry, writing the word "error" above the line, and
initialing the entry - answerD
Word elements used in medical terminology are
A. Suffix, prefix and combining consonant
B. Suffix, prefix and abbreviation
C. Suffix, prefix and root
D. Suffix, prefix and stem - answerC
Which of the following statements is an example of objective data or information?
A. "Mrs. O'Hara reported she felt nauseated."
B. "Mrs. Jones complained of feeling chilled so I closed the window."
C. "Mrs. O'Hara vomited 250cc of fluid after lunch."
D. "Mr. Jones says he has pain in the lower part of his back - answerC
identify the sentence that uses the correct abbreviations to chart the following
statement:
Resident is sitting up in a wheelchair. Have no complaints of pain. Sent to radiology
department for an upper gastrointestinal series.
A. Pt. up in WC. No C/O pain/or rad. For UGI series
B. Pt. up in w/c. CC pain. To x-ray for GI series
C. Pt. up in w/c. No c/o pain. To x-ray for GB series
D. Pt. up in w/c. No c/o pain. To x-ray for UGI series - answerD
What are the ABC's of observation?
A. Appearance, breathing and circulation
B. Airway, breathing and circulation
C. Appearance, behavior and communication
D. Airway, breathing and coughing - answerC
Which of the following most completely defines observation?
A. Watching the activities of the resident
B. Listening to the resident and to staff reports
C. Reading the charts and records
D. Gathering resident information by using the four main senses - answerD
An error made with while writing the resident's chart is corrected by
A. Crossing out the mistake until it can no longer be read
B. Tearing out the sheet and writing on a new one
C. Drawing a line through the wrong entry and explaining why it was an error
D. Drawing a single line through the entry, writing the word "error" above the line, and
initialing the entry - answerD
Word elements used in medical terminology are
A. Suffix, prefix and combining consonant
B. Suffix, prefix and abbreviation
C. Suffix, prefix and root
D. Suffix, prefix and stem - answerC
Which of the following statements is an example of objective data or information?
A. "Mrs. O'Hara reported she felt nauseated."
B. "Mrs. Jones complained of feeling chilled so I closed the window."
C. "Mrs. O'Hara vomited 250cc of fluid after lunch."
D. "Mr. Jones says he has pain in the lower part of his back - answerC
identify the sentence that uses the correct abbreviations to chart the following
statement:
Resident is sitting up in a wheelchair. Have no complaints of pain. Sent to radiology
department for an upper gastrointestinal series.
A. Pt. up in WC. No C/O pain/or rad. For UGI series
B. Pt. up in w/c. CC pain. To x-ray for GI series
C. Pt. up in w/c. No c/o pain. To x-ray for GB series
D. Pt. up in w/c. No c/o pain. To x-ray for UGI series - answerD
What are the ABC's of observation?
A. Appearance, breathing and circulation
B. Airway, breathing and circulation
C. Appearance, behavior and communication
D. Airway, breathing and coughing - answerC
