INP 402 EPICCARE INPATIENT CLINICAL DOCUMENTATION EXAM REVIEW SOLVED
QUESTIONS COMPLETE ANSWERS GRADED A PLUS
● Specific documentation responsibilities and contents of patient health
records are determined by what? Answer: each hospital's medical staff
bylaws and health records committee. However, the general contents are
fundamentally the same. pg, 13
● What are the types of clinical documentation entries? Answer:
Discharge Summary, Problem List, History and Physical, Progress
Notes, Consultation Reports, Diagnostic Test Results, Physician Orders,
Anesthesiology Record, and Operative Reports pg. 13-15
● What is a discharge summary? Answer: a concise synopsis of the
patient's course in the hospital pg. 13
● What is the biggest challenge with the discharge summary? Answer:
Timeliness pg. 13
● Although house staff or midlevel practitioners may compose or dictate
the contents of a patient's discharge summary, the attending physician is
, what and has to do what? Answer: the ultimate author of the discharge
summary and must sign off on it accordingly pg. 13
● What is the remedy for this lack of timeliness? Answer: to add an
additional coding review for every record after the discharge summary
has been completed. pg. 14
● The problem list can be created by whom? Answer: a member of the
house staff of a midlevel practitioner pg. 14
● Who does the ultimate responsibility for the contents of the problem
list remain with? Answer: the attending physician pg. 14
● Documentation in a problem list that is inconsistent with entries in the
patient's record make the list what? Answer: unreliable and, more
importantly, it can result in quality of care concerns for a patient pg. 14
● The patient's history and physical contains documentation that the
physician uses to what? Answer: establish a tentative provisional
diagnosis that will be the basis for treatment pg. 14
● What are essential because all of the clinicians treating the patient rely
upon its content? Answer: Timeliness and legibility of the history and
physical pg. 14
QUESTIONS COMPLETE ANSWERS GRADED A PLUS
● Specific documentation responsibilities and contents of patient health
records are determined by what? Answer: each hospital's medical staff
bylaws and health records committee. However, the general contents are
fundamentally the same. pg, 13
● What are the types of clinical documentation entries? Answer:
Discharge Summary, Problem List, History and Physical, Progress
Notes, Consultation Reports, Diagnostic Test Results, Physician Orders,
Anesthesiology Record, and Operative Reports pg. 13-15
● What is a discharge summary? Answer: a concise synopsis of the
patient's course in the hospital pg. 13
● What is the biggest challenge with the discharge summary? Answer:
Timeliness pg. 13
● Although house staff or midlevel practitioners may compose or dictate
the contents of a patient's discharge summary, the attending physician is
, what and has to do what? Answer: the ultimate author of the discharge
summary and must sign off on it accordingly pg. 13
● What is the remedy for this lack of timeliness? Answer: to add an
additional coding review for every record after the discharge summary
has been completed. pg. 14
● The problem list can be created by whom? Answer: a member of the
house staff of a midlevel practitioner pg. 14
● Who does the ultimate responsibility for the contents of the problem
list remain with? Answer: the attending physician pg. 14
● Documentation in a problem list that is inconsistent with entries in the
patient's record make the list what? Answer: unreliable and, more
importantly, it can result in quality of care concerns for a patient pg. 14
● The patient's history and physical contains documentation that the
physician uses to what? Answer: establish a tentative provisional
diagnosis that will be the basis for treatment pg. 14
● What are essential because all of the clinicians treating the patient rely
upon its content? Answer: Timeliness and legibility of the history and
physical pg. 14
