NURS 522 ADVANCED HEALTH ASSESSMENT EXAM 1.docx

NURS 522 ADVANCED HEALTH
ASSESSMENT EXAM 1

ListoofiveoogeneralooprinciplesooofoodocumentationoothatooareoobasedooonooCMSooguidelin
es.oo-ooans--✔✔a.ooTheoomedicaloorecordooshouldoobeoocompleteooandoolegible.
b.ooTheoodocumentationooofooeachoopatientooencounterooshouldooincludeootheoofollowing:
•ooReasonooforootheooencounterooandoorelevantoohistory,oophysicalooexaminationoofinding
s,ooandoodiagnosticootestooresults
•ooAssessment,ooclinicalooimpression,oooroodiagnosisoo
•ooPlanooforoocareoo
•ooDateooandoolegibleooidentityooofootheoohealth-careooprovider
c.ooIfoonotoodocumented,ootheoorationaleooforooorderingoodiagnosticooandoootherooancillary
ooservicesooshouldoobeooeasilyooinferred.
d.ooPastooandoopresentoodiagnosesooshouldoobeooaccessibleootoootheootreatingooandoocon
sultingooproviders.
e.ooTheoopatient'sooprogress,ooresponseootoooandoochangesooinootreatment,ooandoorevisio
nooofoodiagnosesooshouldoobeoodocumented.

Inooadditionootooootheroohealth-
careooproviders,oolistoofiveoodifferentootypesoooroogroupsooofoopeopleoowhooocouldooreadoo
medicaloorecordsooyouoocreate.oo-ooans--✔✔a.ooAttorneys
b.ooMalpracticeoocarriers
c.ooJurors/Judges
d.ooPatients
e.ooCMS/JCAHO

Describeoohowootooomakeooaoocorrectionooinooaoopaperoomedicaloorecord.oo-ooans--
✔✔Whenoomakingooaoocorrectionooinooaoopaperoorecord,ooyouooshouldoodrawooaoosingleo
olineoothroughootheootextoothatooisooerroneous,ooinitialooandoodateootheooentry,ooandoolabel
ooitooasooanooerror.ooIfoothereooisooroom,ooyouoomayooenterootheoocorrectootextooinootheoosa
meooareaooofootheoonote.ooYouooshouldoonotoowriteooinootheoomarginsooofooaoopage;ooifooth
ereooisoonoooroomootoooenterootheoocorrectootext,oouseooanooaddendumootooorecordootheooi
nformation.ooYouooshouldooneverooobliterateooanoooriginaloonote,oonorooshouldooyouoouse
oocorrectionoofluidooorootape.


Isooitooacceptableoooroounacceptableooaccordingootooogenerallyooacceptedoodocumentatio
nooguidelinesootooouseooeitherooofootheoo1995oooroo1997ooCMSooguidelines?oo-ooans--
✔✔Acceptable

,Isooitooacceptableoooroounacceptableooaccordingootooogenerallyooacceptedoodocumentatio
nooguidelinesootooomakeooaoolateooentryooinooaoochartoooroomedicaloorecord?oo-ooans--
✔✔Acceptable

Isooitooacceptableoooroounacceptableooaccordingootooogenerallyooacceptedoodocumentatio
nooguidelinesootooouseoocorrectionoofluidooorootapeootoooobliterateooanooentryooinooaoorecor
d?oo-ooans--✔✔Unacceptable

Isooitooacceptableoooroounacceptableooaccordingootooogenerallyooacceptedoodocumentatio
nooguidelinesootooomakeooanooentryooinooaoorecordoobeforeooseeingooaoopatient?oo-ooans--
✔✔Acceptable

Isooitooacceptableoooroounacceptableooaccordingootooogenerallyooacceptedoodocumentatio
nooguidelinesootoooalterooanooentryooinooaoomedicaloorecord?oo-ooans--✔✔Unacceptable

Isooitooacceptableoooroounacceptableooaccordingootooogenerallyooacceptedoodocumentatio
nooguidelinesootooostampooaoorecordoo"signedoobutoonotooread"?oo-ooans--
✔✔Unacceptable

TrueooorooFalse?
ooCPToocodesooreflectootheoolevelooofooevaluationooandoomanagementooservicesooprovide
d.oo-ooans--✔✔False

TrueooorooFalse?
ooTheoothreeookeyooelementsooofoodeterminingootheoolevelooofooserviceooareoohistory,oorev
iewooofoosystems,ooandoophysicalooexamination.oo-ooans--✔✔False

TrueooorooFalse?
ooTimeoospentoocounselingootheoopatientooandootheoonatureooofootheoopresentingooproble
mooareootwooofactorsoothatooaffectootheoolevelooofooserviceooprovided.oo-ooans--✔✔True

TrueooorooFalse?ooICDoocodesooindicateootheooreasonooforoopatientooservices.oo-ooans--
✔✔True

TrueooorooFalse?ooTheooICD-
10oocodeoosetoohasoomoreoothanoo155,000oocodes,oobutooitoodoesoonotoohaveootheoocapa
cityootoooaccommodateoonewoodiagnosesooandooprocedures.oo-ooans--✔✔False

TrueooorooFalse?
ooTheoomedicaloorecordoomustooincludeoodocumentationoothatoosupportsootheooassessme
nt.oo-ooans--✔✔True

TrueooorooFalse?
ooAssignmentooofooappropriateooCPTooandooICDoocodesoothatoosupportootheoolevelooofooE
/

,Mooservicesooprovidedooisoodependentooonlyooonooadequateoodocumentationooofootheoohi
storyooandoophysicalooexamination.oo-ooans--✔✔False

TrueooorooFalse?
ooAnooICDoocodeooshouldoobeooasoobroadooandooencompassingooasoopossible.oo-ooans--
✔✔False

TrueooorooFalse?ooThereooisoonooocodeooforoo"ruleooout."oo-ooans--✔✔True

TrueooorooFalse?ooTheoocomplexityooofoomedicaloodecision-
makingootakesoointoooaccountootheoonumberooofootreatmentoooptions.oo-ooans--✔✔True

ICDoocodesooareoousedootoooidentifyoowhat?oo-ooans--
✔✔Physicalooexamoofindings,ooReasonooforooofficeoovisit,ooComplaints,ooDiagnosis,ooSy
mptoms,ooConditions

ListoofiveoofunctionsoothatooanooEMRoosystemooshouldoobeooableootoooperform.oo-ooans--
✔✔Healthooinformationooandoodata
b)ooResultoomanagement
c)ooOrderoomanagement
d)ooDecisionoosupport
e)ooElectronicoocommunicationooandooconnectivity

IdentifyoofiveooperceivedoobenefitsooofooanooEMRoosystem.oo-ooans--
✔✔Anooelectronicoosystemoowouldooprovideooimmediateooaccessootoookeyooinformation,oo
suchooasoodiagnoses,ooallergies,oolaboratoryootestooresults,ooandoomedications,oothatoowo
uldooimproveootheooprovider'sooabilityootooomakeoosoundooclinicaloodecisionsooinooaootimel
yoomanner.
b)ooResultoomanagementoowouldooensureoothatooallooprovidersooparticipatingooinootheooca
reooofooaoopatientoowouldoohaveooquickooaccessootooonewooandoopastootestooresults,oorega
rdlessooofoowhoooorderedootheootests,ootheoogeographicoolocationooofootheooorderingoopro
vider,oooroowhenootheootestsoowereooorderedooorooperformed.
c)ooOrderoomanagementoowouldooincludeootheooabilityootoooenterooandoostoreooordersoofor
ooprescriptions,ootests,ooandoootherooservicesooinooaoocomputer-
basedoosystemoothatoowouldooenhanceoolegibility,ooreduceooduplication,ooreduceoofragme
ntation,ooandooimproveootheoospeedoowithoowhichooordersooareooexecuted.
d)ooUsingooreminders,ooprompts,ooandooalerts,oocomputerizedoodecision-
supportoosystemsoowouldooimproveoocomplianceoowithoobestooclinicaloopractices,ooensure
ooregularooscreeningsooandoootheroopreventiveoopractices,ooidentifyoopossibleoodrug-
drugoooroodrug-diseaseoointeractions,ooandoofacilitateoodiagnosesooandootreatments.
e)ooPatientsoowouldoobeooprovidedootoolsoothatoogiveoothemooaccessootoootheiroohealthoor
ecordsooandoointeractiveoopatientooeducationooandoothatoowouldoohelpoothemoocarryooouto
ohome-monitoringooandooself-testingootoooimproveoocontrolooofoochronicooconditions.


IdentifyooatooleastoofiveoopotentialoobarriersootoooimplementingooanooEMRoosystem.oo-
ooans--✔✔Limitedoocomputerooliteracyooonootheoopartooofooproviders

, b)ooConcernsoooveroosecurity,ooproductivity,oopatientoosatisfaction,ooandoounreliableootec
hnology
c)ooCostsooofoohardwareooandoosoftware
d)ooConcernsooaboutoosafetyooandoosecurityooofoosystemsooandootheooabilityootoooprotecto
oandookeepooprivateooconfidentialoohealthooinformation
e)ooTechnicaloomatters,oosuchooasoofunctionality,ooeaseooofoouse,ooandoocustomeroosupp
ortoofromoovendorsooareoootheroobarriers

Listooatooleastootwooocriteriaoorequiredootooomeetoo"meaningfuloouse"oostandards.oo-
ooans--
✔✔Providersoohaveootoooshowoothatootheyooareoomeetingoocertainoomeasurementoothres
holdsoothatoorangeoofromoorecordingoopatientooinformationooasoostructuredoodataootoooexc
hangingoosummaryoocareoorecords.
b)ooTheooHITECHooActooimposesoorequirementsooforoonotificationooofooaoodataoobreachoor
elatedootooounauthorizedoousesooandoodisclosuresooofoo"unsecuredooprotectedoohealthooi
nformation"oo(PHI).

TrueooorooFalse?
ooHIPAAooestablishesoostandardsooforootheooelectronicootransferooofoohealthoodata.oo-
ooans--✔✔True


TrueooorooFalse?ooProvidesoohealthoocareooforooeveryone.oo-ooans--✔✔False

TrueooorooFalse?ooLimitsooexclusionooofoopre-
existingoomedicalooconditionsootooo24oomonths.oo-ooans--✔✔False

TrueooorooFalse?ooGivesoopatientsoomoreooaccessootoootheiroomedicaloorecords.oo-ooans--
✔✔True

TrueooorooFalse?
ooProtectsoomedicaloorecordsoofromooimproperoousesooandoodisclosures.oo-ooans--
✔✔True

TrueooorooFalse?ooFederalooHIPAAooregulationsoopre-emptoostateoolaws.oo-ooans--
✔✔True

TrueooorooFalse?
ooTheooPrivacyooRuleooappliesooonlyootooocoveredooentitiesoothatootransmitoomedicalooinfo
rmationooelectronically.oo-ooans--✔✔True

TrueooorooFalse?
ooProtectedooHealthooInformationooisoodataoothatoocouldoobeoousedootoooidentifyooanooindiv
idual.oo-ooans--✔✔True