Test Bank for Guide to Clinical Documentation, 3rd Edition by Debra D. Sullivan | Chapters 1–12 | Practice Questions & Answers | Comprehensive Study Guide

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Test Bank for Guide to Clinical Documentation,
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x 3rd Edition by Debra D. Sullivan | Chapters 1–12 |
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x Practice Questions & Answers With rationales |
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x Comprehensive Study Guide x x

,
,Chapter 1: Medicolegal Principles of Documentation x x x x x




Multiple Choice Questions x x




1. According to CMS guidelines, which of the following is NOT one of
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the general principles of documentation?
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• A) The medical record should be complete and legible
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• B) Past and present diagnoses should be accessible to treating and
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consulting providers
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• C) The medical record should include personal opinions about the
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patient's character
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• D) Appropriate health risk factors should be identified
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Answer: C x



Rationale: The CMS guidelines emphasize objective documentation.
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Personal, subjective opinions regarding the patient, the patient's family, or
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other providers do not belong in the medical record. Documentation should
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focus on facts, not opinions.
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2. Which of the following best describes the purpose of the Health
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Insurance Portability and Accountability Act (HIPAA) Privacy Rule?
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• A) To ensure all patients have health insurance coverage
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• B) To protect the confidentiality of individually identifiable health
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information
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• C) To establish standards for electronic prescribing
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• D) To regulate the cost of healthcare services
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Answer: B x



Rationale: The Privacy Rule was written to protect the confidentiality of
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individually identifiable health information. It limits the use and disclosure of
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certain individually identifiable health information and gives patients the
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right to access their medical records.
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, 3. When correcting an error in a paper medical record, the healthcare
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provider should:
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• A) Use correction fluid to cover the error
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• B) Draw a single line through the erroneous text, initial and date the entry,
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and label it as an error
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• C) Completely remove the page and rewrite it
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• D) Write over the erroneous text to make it illegible
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Answer: B x



Rationale: When making a correction in a paper record, you should draw a
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single line through the text that is erroneous, initial and date the entry, and
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label it as an error. You should never obliterate an original note, nor should
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you use correction fluid or tape.
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4. The downcoding process occurs when:
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• A) A patient receives a lower level of care than needed
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• B) An insurance company reduces the value of a procedure and resulting
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reimbursement
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• C) A provider documents an incorrect diagnosis
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• D) A patient is denied coverage for a procedure
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Answer: B x



Rationale: Downcoding is the process by which an insurance company
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reduces the value of a procedure or encounter and resulting reimbursement
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because either (1) there is a mismatch of CPT code and description, or (2) the
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ICD code does not justify the procedure or level of service.
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5. What is the primary purpose of the HITECH Act?
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• A) To provide health insurance for children
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• B) To offer financial incentives for healthcare providers who comply with
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"meaningful use" standards for EMR technology
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• C) To regulate pharmaceutical companies
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• D) To establish standards for medical billing
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