Clinical Documentation Chapter 1 exam ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
with correct answers ||\\||\\ ||\\||\\
List 5 different types or groups of people who could
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
read medical records you create - correct answers
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
✔✔1. attorneys ||\\||\\
2. researchers
||\\||\\
3. patient
||\\||\\
4. insurance companies
||\\||\\ ||\\||\\
5. state/federal payers
||\\||\\ ||\\||\\
List 5 general principles of documentation that are
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
based on CMS guidelines - correct answers ✔✔1. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Record should be complete and legible ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
2. For each encounter document: reason, relevant
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
hx, exam findings/diagnostic test results,
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
assessment, and plan of care. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
3. Date and legible identity of person documenting
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
,4. Rationale for ordering tests and services
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
5. Past and present diagnoses
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
How do you make a correction in a medical record? -
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
correct answers ✔✔Draw a single line through the ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
entry, label it as ||\\||\\ ||\\||\\ ||\\||\\
an error, initial and date it.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Is the use of either the 1995 or 1997 CMS guidelines
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
acceptable or unacceptable? - correct answers ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
✔✔acceptable
Is making a late entry in a chart or medical record
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
acceptable or unacceptable? - correct answers ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
✔✔acceptable
, Is using correction fluid or tape to obliterate an entry
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
in a record acceptable or unacceptable? - correct
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
answers ✔✔unacceptable ||\\||\\
Is making an entry in a record before seeing a patient
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
acceptable or unacceptable? - correct answers ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
✔✔unacceptable
Is amending an entry in a medical record acceptable
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
or unacceptable? - correct answers ✔✔acceptable
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Is stamping a record "signed but not read"
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
acceptable or unacceptable? - correct answers ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
✔✔unacceptable
T or F: CPT codes reflect the level of evalua- tion and
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
management services provided. - correct answers ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
✔✔TRUE
with correct answers ||\\||\\ ||\\||\\
List 5 different types or groups of people who could
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
read medical records you create - correct answers
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
✔✔1. attorneys ||\\||\\
2. researchers
||\\||\\
3. patient
||\\||\\
4. insurance companies
||\\||\\ ||\\||\\
5. state/federal payers
||\\||\\ ||\\||\\
List 5 general principles of documentation that are
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
based on CMS guidelines - correct answers ✔✔1. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Record should be complete and legible ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
2. For each encounter document: reason, relevant
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
hx, exam findings/diagnostic test results,
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
assessment, and plan of care. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
3. Date and legible identity of person documenting
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
,4. Rationale for ordering tests and services
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
5. Past and present diagnoses
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
How do you make a correction in a medical record? -
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
correct answers ✔✔Draw a single line through the ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
entry, label it as ||\\||\\ ||\\||\\ ||\\||\\
an error, initial and date it.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Is the use of either the 1995 or 1997 CMS guidelines
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
acceptable or unacceptable? - correct answers ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
✔✔acceptable
Is making a late entry in a chart or medical record
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
acceptable or unacceptable? - correct answers ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
✔✔acceptable
, Is using correction fluid or tape to obliterate an entry
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
in a record acceptable or unacceptable? - correct
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
answers ✔✔unacceptable ||\\||\\
Is making an entry in a record before seeing a patient
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
acceptable or unacceptable? - correct answers ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
✔✔unacceptable
Is amending an entry in a medical record acceptable
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
or unacceptable? - correct answers ✔✔acceptable
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Is stamping a record "signed but not read"
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
acceptable or unacceptable? - correct answers ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
✔✔unacceptable
T or F: CPT codes reflect the level of evalua- tion and
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
management services provided. - correct answers ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
✔✔TRUE
