1. Fundamentals I: Case studies Unit 1: checking the chart Go here for help with this unit: http://kcweb.nhmccd.edu/programs/respca re/chart_%20interview.doc http://kcweb.nhmccd.edu/programs/respca re/chart_%20interview.doc By Elizabeth Kelley Buzbee AAS, RRT-NPS, RCP

2. Case study #1 You are to give a patient some oxygen. To check the order for exactly how much oxygen is ordered, to which of these parts of the chart do you go? a. The nurse’s graphic b. The doctor’s progress notes c. The physician's order sheet

3. Case study #1 You need to give a patient some oxygen. To check the order for exactly how much oxygen is ordered, to which of these parts of the chart do you go? a. The nurse’s graphic b. The doctor’s progress notes c. The physician's order sheet

4. After you find the order in the physician's order sheet, you need to check for the patient’s most current heart rate and respiratory rate. Where would you go for this information? a. The nurse’s graphic b. The doctor’s progress notes c. The physician's order sheet

5. After you find the order in the physician's order sheet, you need to check for the patient’s most current heart rate and respiratory rate. Where would you go for this information? a. The nurse’s graphic b. The doctor’s progress notes c. The physician's order sheet

6. To discover the doctor’s plan of care for this patient, you would go to what part of the chart? a. The nurse’s graphic b. The doctor’s progress notes c. The physician's order sheet

7. To discover the doctor’s plan of care for this patient, you would go to what part of the chart? a. The nurse’s graphic b. The doctor’s progress notes c. The physician's order sheet

8. Case study #2 your patient is to get some medication on the following schedule: Q 4 hours. This means that he gets medication. – A. every 4 hours – B. 4 times a day

9. Case study #2 your patient is to get some medication on the following schedule: Q 4 hours. This means that he gets medication. – A. every 4 hours – B. 4 times a day

10. If the patient gets the first treatment at 0900, and the treatment is Q 3 hours, when is the next treatment due? – A. 1200 – B. 24:00 – C. at the next meal

11. If the patient gets the first treatment at 0900, and the treatment is Q 3 hours, when is the next treatment due? – A. 1200 – B. 24:00 – C. at the next meal

12. You are looking that the physician’s order sheet and see the following order: Measure vital signs and if heart rate over 125 bpm, call me. You note that the hear rate is 115 bpm. What do you do? a.Call the doctor b.Chart the results c.Both Case study # 3

13. You notice that the nurse’s graphic states that at 1200, the heart rate was 95 at 1400, the heart rate was 98 and at 1600, the heart rate was 110. When do you expect the next documentation of the heart rate? a. At 2100 b. At 1900 c. At 1800

14. You notice that the nurse’s graphic states that at 1200, the heart rate was 95 at 1400, the heart rate was 98 and at 1600, the heart rate was 110. When do you expect the next documentation of the heart rate? a. At 2100 b. At 1900 c. At 1800

15. You notice that the nurse’s graphic states that at 1400, the heart rate was 95 at 1800, the heart rate was 98 and at 2300, the heart rate was 110. What can you say about the tread of the heart rates. a. Heart rate is decreasing b. Heart rate is increasing c. Heart rate is consistent

16. You notice that the nurse’s graphic states that at 1400, the heart rate was 95 at 1800, the heart rate was 98 and at 2300, the heart rate was 110. What can you say about the tread of the heart rates. a. Heart rate is decreasing b. Heart rate is increasing c. Heart rate is consistent

17. You look at the physician’s order sheet to see that the doctor has signed his order, but that the ward clerk [unit secretary] has also signed off and has written a note: “notified RT.” This means that: a. She has called RT department about an order they need to look at b. She has followed this order and is notifying the respiratory care department

18. You look at the physician’s order sheet to see that the doctor has signed his order, but that the ward clerk [unit secretary] has also signed off and has written a note: “notified RT.” This means that: a. She has called RT department about an order they need to look at b. She has followed this order and is notifying the respiratory care department

19. Case study # 4 Before the nurse can give your patient his medicine she needs to check his serum levels of the drug. Where in the chart will she go? a. Into the progress notes b. Into the X-ray [imaging] section c. Into the lab section

20. Case study # 4 Before the nurse can give your patient his medicine she needs to check his serum levels of the drug. Where in the chart will she go? a. Into the progress notes b. Into the X-ray [imaging] section c. Into the lab section

21. The nurses takes an order over the phone, how will you know that this order was not hand written by the doctor. a. You check the hand writing b. You see T/O beside the order c. You see V/O

22. The nurses takes an order over the phone, how will you know that this order was not hand written by the doctor. a. You check the hand writing b. You see T/O beside the order c. You see V/O

23. If the doctor wants to discuss his patient’s overall status, where would the doctor go to chart this? a. Order sheet b. Progress note c. Lab reports

24. If the doctor wants to discuss his patient’s overall status, where would the doctor go to chart this? a. Order sheet b. Progress note c. Lab reports

25. You need to look for an x-ray to check for a pneumothorax before you can give your therapy. Where do you go in the chart. a. Lab reports b. Imaging reports c. Surgery report

26. You need to look for an x-ray to check for a pneumothorax before you can give your therapy. Where do you go in the chart. a. Lab reports b. Imaging reports c. Surgery report

27. You need to find information about your patient’s diagnosis after a tumor was removed. Where do you go? a. Lab reports b. Surgery report c. Imaging reports d. Both a and b might have this information

28. You need to find information about your patient’s diagnosis after a tumor was removed. Where do you go? a. Lab reports b. Surgery report c. Imaging reports d. Both a and b might have this information

29. Case study # 5 Before you can give your patient an incentive spirometry, you need to make sure he will be free of pain. Where do you go to see if pain medication was ordered? a. Progress notes b. Labs c. Physicians order sheet

30. Case study # 5 Before you can give your patient an incentive spirometry, you need to make sure he will be free of pain. Where do you go to see if pain medication was ordered? a. Progress notes b. Labs c. Physicians order sheet

31. Once you check the orders, you need to check when the last time the nurse gave sedation. Where do you go? Nurse’s graphic Medication sheet [MAR] EKG reports Labs

32. Once you check the orders, you need to check when the last time the nurse gave sedation. Where do you go? a.Nurse’s graphic b.Medication sheet [MAR] c.EKG reports d. Labs

33. You need to see what kind of vital signs your patient had in the recovery room in the first few minutes/hours after he had surgery. Where do you go in the chart? a. Imaging b. Medication sheet c. Surgery report d. Recovery room report

34. You need to see what kind of vital signs your patient had in the recovery room in the first few minutes/hours after he had surgery. Where do you go in the chart? a. Imaging b. Medication sheet c. Surgery report d. Recovery room report

35. Now you need to see what the patient’s urine out put was a few hours ago. Where do you go in the chart to get this information. a. Medication sheet b. Nurse’s graphic c. Progress notes d. B will have it for sure, but c might have it

36. Now you need to see what the patient’s urine out put was a few hours ago. Where do you go in the chart to get this information. a. Medication sheet b. Nurse’s graphic c. Progress notes d. B will have it for sure, but c might have it