Mixed Deck — All CKE Topics Flashcards

What does the term 'late entry' mean in medical documentation?

Answer: Documentation entered after the event occurred but still necessary for accurate records

A late entry is documentation added after the event it describes, which must be clearly labeled as a late entry with the date and time it was added.

Which principle requires that documentation accurately reflect the actual care provided without exaggeration or omission?

Answer: Accuracy

Accuracy in documentation means that records must truthfully reflect the care provided, without adding, omitting, or altering facts.

What does the term 'bioavailability' refer to?

Answer: The fraction of a drug that reaches systemic circulation in active form

Bioavailability is the proportion of a drug dose that reaches the systemic circulation in an unchanged, active form.

How do you handle a situation where you are asked to work on a project outside your area of expertise?

Answer: Communicate your concerns to your supervisor, seek guidance, and collaborate with others who have the relevant expertise.

When faced with a project outside one's expertise, the most professional and effective approach is to communicate concerns to a supervisor. Seeking guidance and collaborating with others who possess the relevant expertise ensures the project is handled competently and provides an opportunity for learning. This demonstrates responsibility, teamwork, and a proactive attitude towards challenges.

What is management?

Answer: The art and science of getting the objectives of the organization accomplished through and with people.

Management is defined as the art and science of coordinating and overseeing the activities of others to achieve organizational objectives. It involves planning, organizing, leading, and controlling resources, particularly human resources, to effectively meet the goals of an organization.

Which of the following must be kept confidential under HIPAA?

Answer: Patient's treatment plan and medical history

HIPAA protects all individually identifiable health information, including treatment plans and medical histories, known as PHI.

What is a sentinel event in patient safety terms?

Answer: An unexpected event resulting in death or serious harm

A sentinel event is an unexpected patient safety event that results in death, permanent harm, or severe temporary harm requiring intervention.

What does the WHO '5 Moments for Hand Hygiene' initiative address?

Answer: Five specific moments when hand hygiene is critical in patient care

The WHO's 5 Moments for Hand Hygiene identifies five critical times hand hygiene must be performed during patient care to prevent infection.

What is the purpose of a HIPAA Notice of Privacy Practices?

Answer: To inform patients how their health information may be used

A HIPAA Notice of Privacy Practices explains to patients how their protected health information (PHI) may be used and shared.

What is the purpose of malpractice insurance for healthcare providers?

Answer: To protect providers financially against negligence claims

Malpractice insurance protects healthcare providers from financial liability in cases where they are sued for negligence or errors.

What is an adverse drug reaction (ADR)?

Answer: An unintended harmful response to a drug given at normal doses

An adverse drug reaction is an unintended, harmful response that occurs at normal therapeutic doses of a medication.

Hypotension in adults is generally defined as a systolic blood pressure below:

Answer: 90 mmHg

Hypotension is typically defined as systolic BP below 90 mmHg, though clinical context and the patient's baseline must also be considered.

The suffix '-ectomy' refers to which type of procedure?

Answer: Surgical removal

The suffix '-ectomy' means surgical removal, such as appendectomy (removal of the appendix).

A normal pulse oximetry (SpO₂) reading for a healthy adult at sea level is:

Answer: 95–100%

A SpO₂ of 95–100% indicates adequate oxygen saturation; readings below 95% warrant further clinical evaluation.

To what does the term “hypochondriac” refer?

Answer: The region of abdomen inferior to the ribs.

In anatomical terminology, the term 'hypochondriac' refers to one of the nine regions used to divide the abdomen. Specifically, the left and right hypochondriac regions are located on either side of the epigastric region, situated inferior to the ribs and costal cartilages. This term literally means 'under the cartilage,' accurately describing its position beneath the lower ribs.

Which route of drug administration provides the fastest onset of action?

Answer: Intravenous

Intravenous (IV) administration delivers drugs directly into the bloodstream, providing the fastest onset of action.

EMTALA requires emergency departments to do which of the following?

Answer: Provide emergency screening and stabilization regardless of ability to pay

EMTALA (Emergency Medical Treatment and Labor Act) requires hospitals to screen and stabilize any patient presenting to an ED regardless of payment ability.

What is the function of CPT codes in healthcare documentation?

Answer: Describe and bill for medical procedures and services

CPT (Current Procedural Terminology) codes describe and report medical procedures and services for billing and statistical purposes.

A resting heart rate above 100 beats per minute in an adult is termed:

Answer: Tachycardia

Tachycardia is defined as a heart rate exceeding 100 bpm at rest and may indicate fever, dehydration, pain, cardiac conditions, or other underlying problems.

Which element is considered part of the subjective section of a SOAP note?

Answer: Chief complaint in the patient's own words

The subjective section of a SOAP note includes information provided by the patient, such as their chief complaint and symptoms.