Question

PLEASE ANSWER THE FOLLOWING:

1. The decision to withhold or withdraw medical treatment are based primarily on:

A.	Statutes and regulations
B.	Adequate communication among providers, patients, and families
C.	The will of the patient surrogate
D.	None of the above

2. Essential medical record components include:: Select three that apply

A.	Documentation and findings of assessments
B.	Diagnostic procedures, tests and results
C.	Reports of adverse events/incidents
D.	Subjective comments
E.	Medications ordered and administered

3. Record retention depends upon factors such as statutes of limitation, state statutes and various standards and regulations promulgated by: Select which one that does not apply.

A.	The Joint Commission (or other accrediting body)
B.	Occupational Safety and Health Administration (OSHA)
C.	Physician Preference
D.	Federal /State reimbursement requirement guidelines (Medicare/Medicaid)
E.	Healthcare and provider licensure requirements

4. In a hard copy medical record, the biggest documentation challenge is?

A.	Legibility
B.	Non-approved abbreviations
C.	Alterations
D.	Subjective comments

Answer 1

Q.1. Option B is correct

Because as per the medical code of ethics the decision to withhold or withdraw medical treatment are based primarily on the basis of the shared communication among providers, patients, and families

Q.2 Options B, C & E are correct and essential medical record components

Q.3. Option E is not applied as

Rest all are essential as

Record retention depends upon factors such as statutes of limitation, state statutes and various standards and regulations promulgate by OSHA, The Joint Commission or other similar accrediting body, physician reference and Federal /State reimbursement requirement guidelines (Medicare/Medicaid)

Q.4. Option A is correct

Because the challenges with hard copy medical recordis legibility. Generally the hand written and the printed documenta are not legible means that clear enough to be read the document.