NURS 522 Advanced health assessment exam 1 questions and answers with solutions 2025

List five general principles of documentation that are based on CMS guidelines. - ANSWER a. The medical record should be complete and legible. b. The documentation of each patient encounter should include the following: • Reason for the encounter and relevant history, physical examination findings, and diagnostic test results • Assessment, clinical impression, or diagnosis • Plan for care • Date and legible identity of the health-care provider c. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. d. Past and present diagnoses should be accessible to the treating and consulting providers. e. The patient's progress, response to and changes in treatment, and revision of diagnoses should be documented. In addition to other health-care providers, list five different types or groups of people who could read medical records you create. - ANSWER a. Attorneys b. Malpractice carriers c. Jurors/Judges d. Patients e. CMS/JCAHO Describe how to make a correction in a paper medical record. - ANSWER When making a correction in a paper record, you should draw a single line through the text that is erroneous, initial and date the entry, and label it as an error. If there is room, you may enter the correct text in the same area of the note. You should not write in the margins of a page; if there is no room to enter the correct text, use an addendum to record the information. You should never obliterate an original note, nor should you use correction fluid or tape.