NURS 5220 ADVANCED HEALTH
ASSESSMENT TEST BANK BUNDLED 2026
TESTED QUESTIONS AND COMPLETE
SOLUTIONS GRADED A+
⩥ 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.
,⩥ Is it acceptable or unacceptable according to generally accepted
documentation guidelines to use either of the 1995 or 1997 CMS
guidelines? Answer: Acceptable
⩥ Is it acceptable or unacceptable according to generally accepted
documentation guidelines to make a late entry in a chart or medical
record? Answer: Acceptable
⩥ Is it acceptable or unacceptable according to generally accepted
documentation guidelines to use correction fluid or tape to obliterate an
entry in a record? Answer: Unacceptable
⩥ Is it acceptable or unacceptable according to generally accepted
documentation guidelines to make an entry in a record before seeing a
patient? Answer: Acceptable
⩥ Is it acceptable or unacceptable according to generally accepted
documentation guidelines to alter an entry in a medical record? Answer:
Unacceptable
⩥ Is it acceptable or unacceptable according to generally accepted
documentation guidelines to stamp a record "signed but not read"?
Answer: Unacceptable
,⩥ True or False? CPT codes reflect the level of evaluation and
management services provided. Answer: False
⩥ True or False? The three key elements of determining the level of
service are history, review of systems, and physical examination.
Answer: False
⩥ True or False? Time spent counseling the patient and the nature of the
presenting problem are two factors that affect the level of service
provided. Answer: True
⩥ True or False? ICD codes indicate the reason for patient services.
Answer: True
⩥ True or False? The ICD-10 code set has more than 155,000 codes, but
it does not have the capacity to accommodate new diagnoses and
procedures. Answer: False
⩥ True or False? The medical record must include documentation that
supports the assessment. Answer: True
⩥ True or False? Assignment of appropriate CPT and ICD codes that
support the level of E/M services provided is dependent only on
adequate documentation of the history and physical examination.
Answer: False
, ⩥ True or False? An ICD code should be as broad and encompassing as
possible. Answer: False
⩥ True or False? There is no code for "rule out." Answer: True
⩥ True or False? The complexity of medical decision-making takes into
account the number of treatment options. Answer: True
⩥ ICD codes are used to identify what? Answer: Physical exam findings,
Reason for office visit, Complaints, Diagnosis, Symptoms, Conditions
⩥ List five functions that an EMR system should be able to perform.
Answer: Health information and data
b) Result management
c) Order management
d) Decision support
e) Electronic communication and connectivity
⩥ Identify five perceived benefits of an EMR system. Answer: An
electronic system would provide immediate access to key information,
such as diagnoses, allergies, laboratory test results, and medications, that
would improve the provider's ability to make sound clinical decisions in
a timely manner.
ASSESSMENT TEST BANK BUNDLED 2026
TESTED QUESTIONS AND COMPLETE
SOLUTIONS GRADED A+
⩥ 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.
,⩥ Is it acceptable or unacceptable according to generally accepted
documentation guidelines to use either of the 1995 or 1997 CMS
guidelines? Answer: Acceptable
⩥ Is it acceptable or unacceptable according to generally accepted
documentation guidelines to make a late entry in a chart or medical
record? Answer: Acceptable
⩥ Is it acceptable or unacceptable according to generally accepted
documentation guidelines to use correction fluid or tape to obliterate an
entry in a record? Answer: Unacceptable
⩥ Is it acceptable or unacceptable according to generally accepted
documentation guidelines to make an entry in a record before seeing a
patient? Answer: Acceptable
⩥ Is it acceptable or unacceptable according to generally accepted
documentation guidelines to alter an entry in a medical record? Answer:
Unacceptable
⩥ Is it acceptable or unacceptable according to generally accepted
documentation guidelines to stamp a record "signed but not read"?
Answer: Unacceptable
,⩥ True or False? CPT codes reflect the level of evaluation and
management services provided. Answer: False
⩥ True or False? The three key elements of determining the level of
service are history, review of systems, and physical examination.
Answer: False
⩥ True or False? Time spent counseling the patient and the nature of the
presenting problem are two factors that affect the level of service
provided. Answer: True
⩥ True or False? ICD codes indicate the reason for patient services.
Answer: True
⩥ True or False? The ICD-10 code set has more than 155,000 codes, but
it does not have the capacity to accommodate new diagnoses and
procedures. Answer: False
⩥ True or False? The medical record must include documentation that
supports the assessment. Answer: True
⩥ True or False? Assignment of appropriate CPT and ICD codes that
support the level of E/M services provided is dependent only on
adequate documentation of the history and physical examination.
Answer: False
, ⩥ True or False? An ICD code should be as broad and encompassing as
possible. Answer: False
⩥ True or False? There is no code for "rule out." Answer: True
⩥ True or False? The complexity of medical decision-making takes into
account the number of treatment options. Answer: True
⩥ ICD codes are used to identify what? Answer: Physical exam findings,
Reason for office visit, Complaints, Diagnosis, Symptoms, Conditions
⩥ List five functions that an EMR system should be able to perform.
Answer: Health information and data
b) Result management
c) Order management
d) Decision support
e) Electronic communication and connectivity
⩥ Identify five perceived benefits of an EMR system. Answer: An
electronic system would provide immediate access to key information,
such as diagnoses, allergies, laboratory test results, and medications, that
would improve the provider's ability to make sound clinical decisions in
a timely manner.
