CMY3702 EXAM SOLVED QUESTIONS AND
VERIFIED SOLUTIONS
◉ The best scientific data available for clinical documentation is also
known as
Answer: Evidence-based medicine
◉ The two-part theory for high-quality clinical documentation is a
cause-and-effect theory that is derived from which two sources?
Answer: Legal/Regulatory Sources and Peer-Reviewed Research
◉ When discussing completeness in a health record, the physician
has fully addressed all concerns, as well as what other
authentication?
Answer: Signature and date
◉ Peer-reviewed academic literature states that this factor shows a
relationship to quality of care as well as support for concurrent CDI
programs:
Answer: Documentation
◉ What evidence supports the lack of high-quality clinical
documentation in the medical field?
,Answer: CDI is not taught in medical school
◉ Which item is not recommended by the HHS and the OIG for
minimum compliance with clinical documentation regulations?
Answer: Physicians should include vaccination records
◉ What does "reliable" in high-quality clinical documentation mean?
Answer: Physician documentation supports medical treatment
◉ Which item is an important aspect of consistent high-quality
clinical documentation?
Answer: Creates a clear picture for subsequent reviewers of
documentation
◉ Which aspect of the discharge summary is the biggest challenge to
house staff, mid-level practitioners, and attending physicians as they
compose the patient's discharge summary?
Answer: Timeliness
◉ Which aspect of the patient's health record can a member of the
house staff or midlevel practitioner create, yet ultimately needs the
attending physician to confirm accuracy?
Answer: Problem list
,◉ Interns, residents, and fellows are physicians with lesser
accountability due to their inability to act as an attending physician
and are also known as ______.
Answer: House staff
◉ Which two medical professionals serve as mid-level practitioners
by supporting physicians in the delivery of care?
Answer: Nurse practitioners and physician assistants
◉ In 1982, which aspect of medical billing/reimbursement
increased the demand for accuracy and timeliness with regard to
medical coding?
Answer: Reimbursement was driven by codes assigned to patient
care
◉ Which hands-on provider's documentation should the coder not
use for final coding?
Answer: Diagnostic radiologist
◉ Which practitioners, along with coding professionals, are
proficient at picking up deficiencies in clinical documentation yet
must focus on giving care?
Answer: Nurses
, ◉ Which healthcare setting requires high levels of proactivity from
management and clinical teams to ensure accurate and timely
clinical documentation?
Answer: Outpatient
◉ Which item is not an inpatient healthcare setting?
Answer: Emergency department
◉ High-quality clinical documentation is the basis for what
standard?
Answer: Gold standard
◉ What allows the diagnostic, treatment, and response of
information of the patient to be aggregated into a uniform data set?
Answer: Coding
◉ What part of the health record, usually located at the end the
document, provides a complete picture of the patient's diagnosis?
Answer: Impression and plan
◉ What description is an aspect of the coding professionals' job?
Answer: Asking the physician about any gaps in documentation that
may represent an insufficiently documented diagnosis
VERIFIED SOLUTIONS
◉ The best scientific data available for clinical documentation is also
known as
Answer: Evidence-based medicine
◉ The two-part theory for high-quality clinical documentation is a
cause-and-effect theory that is derived from which two sources?
Answer: Legal/Regulatory Sources and Peer-Reviewed Research
◉ When discussing completeness in a health record, the physician
has fully addressed all concerns, as well as what other
authentication?
Answer: Signature and date
◉ Peer-reviewed academic literature states that this factor shows a
relationship to quality of care as well as support for concurrent CDI
programs:
Answer: Documentation
◉ What evidence supports the lack of high-quality clinical
documentation in the medical field?
,Answer: CDI is not taught in medical school
◉ Which item is not recommended by the HHS and the OIG for
minimum compliance with clinical documentation regulations?
Answer: Physicians should include vaccination records
◉ What does "reliable" in high-quality clinical documentation mean?
Answer: Physician documentation supports medical treatment
◉ Which item is an important aspect of consistent high-quality
clinical documentation?
Answer: Creates a clear picture for subsequent reviewers of
documentation
◉ Which aspect of the discharge summary is the biggest challenge to
house staff, mid-level practitioners, and attending physicians as they
compose the patient's discharge summary?
Answer: Timeliness
◉ Which aspect of the patient's health record can a member of the
house staff or midlevel practitioner create, yet ultimately needs the
attending physician to confirm accuracy?
Answer: Problem list
,◉ Interns, residents, and fellows are physicians with lesser
accountability due to their inability to act as an attending physician
and are also known as ______.
Answer: House staff
◉ Which two medical professionals serve as mid-level practitioners
by supporting physicians in the delivery of care?
Answer: Nurse practitioners and physician assistants
◉ In 1982, which aspect of medical billing/reimbursement
increased the demand for accuracy and timeliness with regard to
medical coding?
Answer: Reimbursement was driven by codes assigned to patient
care
◉ Which hands-on provider's documentation should the coder not
use for final coding?
Answer: Diagnostic radiologist
◉ Which practitioners, along with coding professionals, are
proficient at picking up deficiencies in clinical documentation yet
must focus on giving care?
Answer: Nurses
, ◉ Which healthcare setting requires high levels of proactivity from
management and clinical teams to ensure accurate and timely
clinical documentation?
Answer: Outpatient
◉ Which item is not an inpatient healthcare setting?
Answer: Emergency department
◉ High-quality clinical documentation is the basis for what
standard?
Answer: Gold standard
◉ What allows the diagnostic, treatment, and response of
information of the patient to be aggregated into a uniform data set?
Answer: Coding
◉ What part of the health record, usually located at the end the
document, provides a complete picture of the patient's diagnosis?
Answer: Impression and plan
◉ What description is an aspect of the coding professionals' job?
Answer: Asking the physician about any gaps in documentation that
may represent an insufficiently documented diagnosis
