INP 402 EPICCARE INPATIENT CLINICAL DOCUMENTATION COMPREHENSIVE EXAM
SCRIPT COMPLETE QUESTIONS VERIFIED SOLUTIONS
● If it isn't documented, it didn't happen. If it didn't happen, you can't
_____ it.
Multiple choice question. Answer: code
● Select the source documents that are in patients' records and used to
abstract information for coding. Answer: -History and physical
-Operative reports
-Physician's notes
-Registration form
● You are required to code all _______ documented to be relevant
during the encounter or hospital stay as per the coding guidelines.
Answer: conditions
● A(n) ______ can report codes for the administration of anesthesia
Answer: anesthesiologist
, ● The documentation about the encounter between the physician and the
_________ is the primary source for details used to code. Answer:
patient
● Which of the following patient encounters might be assigned that is
NOT actually a procedure, service, or treatment? Answer: second
opinion
● _______ is an exact science; it involves changing information from
one language to another. Answer: interpreting
● Diagnosis codes, for reimbursement or statistical purposes, will only
report __________ addressed by the provider during a specific
encounter and not the patient's entire health history. Answer: conditions
● This source documentation is written by the admitting physician and
explains the background and current issues used to make the decision to
admit the patient into the hospital. Answer: history and physical
● In abstracting, the procedures or services that occurred are known as
the _________. Answer: what
● When a patient is discharged from the hospital without a confirmed
diagnosis, the suspected conditions listed on the discharge summary are
coded as if they were _________. Answer: confirmed
SCRIPT COMPLETE QUESTIONS VERIFIED SOLUTIONS
● If it isn't documented, it didn't happen. If it didn't happen, you can't
_____ it.
Multiple choice question. Answer: code
● Select the source documents that are in patients' records and used to
abstract information for coding. Answer: -History and physical
-Operative reports
-Physician's notes
-Registration form
● You are required to code all _______ documented to be relevant
during the encounter or hospital stay as per the coding guidelines.
Answer: conditions
● A(n) ______ can report codes for the administration of anesthesia
Answer: anesthesiologist
, ● The documentation about the encounter between the physician and the
_________ is the primary source for details used to code. Answer:
patient
● Which of the following patient encounters might be assigned that is
NOT actually a procedure, service, or treatment? Answer: second
opinion
● _______ is an exact science; it involves changing information from
one language to another. Answer: interpreting
● Diagnosis codes, for reimbursement or statistical purposes, will only
report __________ addressed by the provider during a specific
encounter and not the patient's entire health history. Answer: conditions
● This source documentation is written by the admitting physician and
explains the background and current issues used to make the decision to
admit the patient into the hospital. Answer: history and physical
● In abstracting, the procedures or services that occurred are known as
the _________. Answer: what
● When a patient is discharged from the hospital without a confirmed
diagnosis, the suspected conditions listed on the discharge summary are
coded as if they were _________. Answer: confirmed
