Week 4 Domain 3 Health Records Quiz
Questions and Complete Solutions
Graded A+
Based on the following documentation in an acute care record, where would you expect this excerpt to
appear?
Initially the patient was admitted to the medical unit to evaluate the x-ray findings and the rub. He was
started on Levaquin 500 mg initially and then 250 mg daily. The patient was hydrated with IV fluids and
remained afebrile. Serial cardiac enzymes were done. The rub, chest pain, and shortness of breath
resolved. EKGs remained unchanged. Patient will be discharged and followed as an outpatient.
clinical laboratory report
admission note
discharge summary
physical exam - Answer: discharge summary
Discharge summary is a document completed by the attending physician when the patient leaves the
hospital. The goal is to communicate thepatient's care plan to the post-hospital provider. The excerpt
clearly indicates an overall summary of the patient's course in the hospital. Wronganswers: 1) Admission
note is part of a medical record that documents the patient's status at the time of admission including
the reasons why thepatient is being admitted for care. 2) Physical exam routine examination performed
by the healthcare provider to assess the patient's overallhealth status. 3) Clinical laboratory report are
laboratory tests done on specimens in order to determine the health of a patient.
Ultimate responsibility for the quality and completion of entries in patient health records belongs to the
HIM director.
,chief of staff.
attending physician.
risk manager. - Answer: attending physician
Although the nursing staff, hospital administration, and the health information management director
play a role in ensuring an accurate and complete record, the major responsibility lies with the attending
physician.
John, a 22-year-old male, told Dr. Paulson that he hit his head at work, hard. His buddy stated that John
had lost consciousness for about a minute. Dr. Paulson orders an MRI of the patient's brain and an x-ray
of his skull. Then, John mentioned that he hurt his shoulder when he fell, so Dr. Paulson added an x-ray
of the left shoulder. Radiologist's report confirms a brain concussion, and shoulder image was negative.
Dx: Brain concussion. Px: E/M, Brain MRI, X-ray Skull, X-ray Shoulder.
Determine What critical information is missing?
Medical necessity for shoulder x-ray
John's buddy's name
Medical necessity for skull x-ray
Length of time patient was unconscious - Answer: Medical necessity for shoulder x-ray
There is a diagnostic statement of the brain concussion to support the Evaluation and Management
(E/M), the MRI of the brain, and the skull x-ray. However, there is no documentation of a diagnosis to
provided medical necessity of the shoulder x-ray. Therefore, medical necessity for shoulder x-ray is the
critical information that is missing. John's buddy's name and the length of time the patient was
unconscious are not necessary in the documentation.
, Determine the primary focus of screen format design in a health record computer application should be
to ensure that
data fields can be randomly accessed.
the user is capturing essential data elements.
paper forms are easily converted to computer forms.
programmers develop standard screen formats for all hospitals. - Answer: the user is capturing essential
data elements.
Both paper-based and computer-based records share similar design considerations. Among these are
the selection and sequencing of essential data items.
The utilization review coordinator reviews inpatient records at regular intervals to justify necessity and
appropriateness of care to warrant further hospitalization. Which of the following utilization review
activities is being performed?
preadmission
continued stay review
admission review
retrospective review - Answer: continued stay review
A continued stay review documents the necessity that each day of hospitalization is required, and
treatment is being provided at the appropriatelevel. The phrase "to warrant further hospitalization"
directly indicates the review is for continued stay. Wrong answers: 1) Admission reviewdetermination of
medical necessity as to whether hospitalizing is appropriate. 2) Pre-admission review refers to approval
Questions and Complete Solutions
Graded A+
Based on the following documentation in an acute care record, where would you expect this excerpt to
appear?
Initially the patient was admitted to the medical unit to evaluate the x-ray findings and the rub. He was
started on Levaquin 500 mg initially and then 250 mg daily. The patient was hydrated with IV fluids and
remained afebrile. Serial cardiac enzymes were done. The rub, chest pain, and shortness of breath
resolved. EKGs remained unchanged. Patient will be discharged and followed as an outpatient.
clinical laboratory report
admission note
discharge summary
physical exam - Answer: discharge summary
Discharge summary is a document completed by the attending physician when the patient leaves the
hospital. The goal is to communicate thepatient's care plan to the post-hospital provider. The excerpt
clearly indicates an overall summary of the patient's course in the hospital. Wronganswers: 1) Admission
note is part of a medical record that documents the patient's status at the time of admission including
the reasons why thepatient is being admitted for care. 2) Physical exam routine examination performed
by the healthcare provider to assess the patient's overallhealth status. 3) Clinical laboratory report are
laboratory tests done on specimens in order to determine the health of a patient.
Ultimate responsibility for the quality and completion of entries in patient health records belongs to the
HIM director.
,chief of staff.
attending physician.
risk manager. - Answer: attending physician
Although the nursing staff, hospital administration, and the health information management director
play a role in ensuring an accurate and complete record, the major responsibility lies with the attending
physician.
John, a 22-year-old male, told Dr. Paulson that he hit his head at work, hard. His buddy stated that John
had lost consciousness for about a minute. Dr. Paulson orders an MRI of the patient's brain and an x-ray
of his skull. Then, John mentioned that he hurt his shoulder when he fell, so Dr. Paulson added an x-ray
of the left shoulder. Radiologist's report confirms a brain concussion, and shoulder image was negative.
Dx: Brain concussion. Px: E/M, Brain MRI, X-ray Skull, X-ray Shoulder.
Determine What critical information is missing?
Medical necessity for shoulder x-ray
John's buddy's name
Medical necessity for skull x-ray
Length of time patient was unconscious - Answer: Medical necessity for shoulder x-ray
There is a diagnostic statement of the brain concussion to support the Evaluation and Management
(E/M), the MRI of the brain, and the skull x-ray. However, there is no documentation of a diagnosis to
provided medical necessity of the shoulder x-ray. Therefore, medical necessity for shoulder x-ray is the
critical information that is missing. John's buddy's name and the length of time the patient was
unconscious are not necessary in the documentation.
, Determine the primary focus of screen format design in a health record computer application should be
to ensure that
data fields can be randomly accessed.
the user is capturing essential data elements.
paper forms are easily converted to computer forms.
programmers develop standard screen formats for all hospitals. - Answer: the user is capturing essential
data elements.
Both paper-based and computer-based records share similar design considerations. Among these are
the selection and sequencing of essential data items.
The utilization review coordinator reviews inpatient records at regular intervals to justify necessity and
appropriateness of care to warrant further hospitalization. Which of the following utilization review
activities is being performed?
preadmission
continued stay review
admission review
retrospective review - Answer: continued stay review
A continued stay review documents the necessity that each day of hospitalization is required, and
treatment is being provided at the appropriatelevel. The phrase "to warrant further hospitalization"
directly indicates the review is for continued stay. Wrong answers: 1) Admission reviewdetermination of
medical necessity as to whether hospitalizing is appropriate. 2) Pre-admission review refers to approval
