Chapter 4 CIC Documentation and Coding Standards Questions and Answers Updated 2026

Chapter 4 CIC Documentation and
Coding Standards Questions and
Answers Updated 2026
RecognizeBtheBlimitationsBofBEHRBandBhowBdowntimeBisBhandledB-
BAnswerAllBhospitalsBhaveBstepsBinBplaceBforBdowntime

-NecessaryBtoBensureBthatBpatientsBmedicalBrecordBisBcomplete

-
PaperBformsBtoBrecordBallBcomputerBtransactionBsuchBasBphysicianBorders,BtransferBofBpatient
BfromBoneBdepartmentBtoBanother,BMedicationBadministration,BandBotherBrequiredBelementsB
ofBtheBMR.B

-IfBshortBpersonnelBcanBenterBtheBinfoBintoBsystemB

-
IfBlong,BpaperBMRBwillBbeBkept,Bsigned,BandBdatedBbyBappropriateBpersonnelBandBscannedBi
ntoBtheBpatientBpermanentBelectronicBMRBafterBtheyBareBdischargedBfromBhospital



IdentifyBdocumentationBdeficienciesBcausedBbyBcopy/pasteBandBuseBofBtemplatesB-
BAnswerCopyBandBPasteBmakesBitBeasyBforBprovidersBtoBuseBinformationBfromBaBpreviousBen
counterBthatBremainsBtheBsame.BIfBusedBimproperly,BprovidersBcanBincludeBinformationBinBth
eBMRBthatBdidBnotBoccur.BProvidersBandBfacilitiesBareBadvisedBnotBtoBuseBcopyBandBpaste.B
MakesBitBdifficultBtoBdetermineBwhatBtreatmentBtheBpatientBreceivedBonBtheBencounterBdate.
BClonedBrecordsBwillBnotBsupportBtheBservicesBbilled.B



TemplatesBcanBbeBaBdownfallBforBMRBifBaBstandardBformBisBusedBforBeveryBprocedureBwitho
utBupdatingBanyBdifferencesBfromBoneBprocedureBtoBtheBnext.B(ex.BCardiacBcath,BifBtemplate
BcannotBstateBactualBnumberBofBcathetersBusedBorBexactBareasBheartBwasBexplored)BIncorrec
tBdocumentation.B

-
NeedBtoBmakeBsureBreportBcanBbeBchangedBsoBtheBexactBprocedureBstepsBareBrecordedBacc
urately.



ExplainBHIPAABsecurityBandBprivacyB-
BAnswerTheBHealthBInsuranceBPortabilityBandBAccountabilityBActBofB1996B(HIPPA)-
BcreatedBtoBprotectBindividualsBagainstBtheBlossBorBdecreaseBinBbenefitsBrelatedBtoBworkBstat
usBandBtoBstandardizeBtheBwayBtheBinformationBaboutBanBindividual'sBhealthBisBtransmittedB
andBhowBtheBinformationBisBprotectedBfromBunwarrantedBintrusion.BTheBadministrativeBsimpli
ficationBprocessBaddressesBelectronicBtransmissionBofBmedicalBclaimsBwhichBisBrequiredBforBall
BMedicareBclaimsBsubmittedBbyBcoveredBentitiesB

, PhysiciansBandBhospitalsBmustBsetBupBsafeguardsBforBtheBgathering,Bstoring,Buse,BandBdisclos
ureBofBidentifiableBpatientBinformationB



AnyBstateBmayBsetBupBadditionalBlaws,BbutBmustBfollowBtheBHIPPABminimumB

NationalBstandardsBinclude:B

-
theBrightBofBtheBpatientBtoBseeBaBcopy,BandBrequestBtoBamendBhisBorBherBownBMR.BTheBpr
oviderBcanBchargeBforBcopiesBofBrecords,BbutBHIPPABsetBlimitsBonBfees

-
ProviderBmustBgiveBpatientBnoticeBofBHIPPABprivacyBruleBandBkeepBanBaccountingBofBdisclosu
resBtoBrecordBhowBeachBdocumentBmayBhaveBbeenBdisclosed.B

-ProvidersBmustBmakeBexceptionsBtoBtheBwayBMRBinfoBisBconveyedBperBpatientBrequestB



TheBOfficeBofBCivilBRightsB(OCR)BofBtheBDepartmentBofBHealthBandBHumanBSerivicesBisBrespo
nsibleBforBimplementationBandBoversightBofBprivacyBregulations



DefineBtheBreportingBrequirementsBunderBMDSB(MinimumBDataBSet)B-
BAnswerMDSBrequiredBbyBCMSBforBnursingBfacilitiesBusedBtoBimplementBstandardizedBassessm
entBandBManagmentBofBcare.BMDsBisBmandatedBprocessBforBallBresidenceBinBaBMedicareBorB
MedicaidBnursingBfacility.BTheBtoolBhasBbeenBexpandedBtoBreportBqualityBofBcareBissues;Band
BisBusedBforBreimbursementBunderBtheBSNFBprospectiveBpaymentBsystemB(PPS)



DemonstrateBtheBproperBprocedureBforBaddendumsBandBalterationsBtoBtheBmedialBrecordB-
BAnswerTheBMRBisBaBlegalBdocument,BWehBcorrectingBtheBMR,BproperBprocedureBisBtoBstrik
eBthroughBtheBincorrectBinformationBwithBaBsingleBline,BincludeBtheBdate,BandBapplyBtheBfirs
tBinitialBandBlastBnameBofBtheBpersonBmakingBtheBcorrection.BThen,BadditionalBinformationBc
anBbeBadded.BInformationBthatBwasBdocumentedBshouldBneverBbeBcompletelyBobliteratedBorB
permanentlyBremovedBfromBtheBMR



IdentifyBcomponentsBofBtheBmedicalBrecordB-BAnswer-
ClinicalBdocumentation,BadministrativeBinfo,BandBdemographicBinfo



DemographicBdataBincudes

-FullBname

-address

-phoneB#

-ethnicityB