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NCLEX practice question Documentation Questions That Actually Appear in Tests

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ist actual time of discharge, mode of transportation, and who accompanied the patient for discharge summary information. In some settings, a Kardex, a portable "flip-over" file or notebook, is kept at the nurses' station. A Kardex is for nurses, not for patients to take upon discharge. A nurse completes a nursing history form when a patient is admitted to a nursing unit, not when the patient is discharged. SOAP notes are not given to patients who are being discharged. SOAP notes are a type of documentation style What does being "Complete" mean? A) Documentation containing appropriate and essential information B) A list of patients food likes and dislikes. C) A full narrative of how the patient was cared for. - Correct Answer ️ ️A

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Institution
CDI
Module
CDI

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CDI Prep Questions With
Comprehensive Answers

C. Diagnostic radiologist - Correct Answer ✔️✔️Which of the following

hands-on provider's documentation should the coder not use for final coding?


A. Attending physician


B. Surgeon


C. Diagnostic radiologist


D. Interventional cardiologis


B. Nurses - Correct Answer ✔️✔️Which practitioners, along with coding

professionals, are proficient at picking up deficiencies in clinical documentation

yet must focus on giving care?


A. Mid-level practitioners


B. Nurses


C. Surgeons


D. Consultants

,D. Outpatient - Correct Answer ✔️✔️Which healthcare setting requires

high levels of proactivity from management and clinical teams to ensure accurate

and timely clinical documentation?


A. Physical therapy


B. Emergency department


C. Inpatient


D. Outpatient


A. Emergency department - Correct Answer ✔️✔️Which of the below items

is not an inpatient healthcare setting?


A. Emergency department


B. Rehabilitation facilities


C. Skilled Nursing facilities


C. Sub Acute facilities


C. Gold standard - Correct Answer ✔️✔️High-quality clinical documentation

is the basis for what standard?


A. The Joint Commission

, B. Clinical documentation improvement standard


C. Gold standard


D. AHIMA regulatory standard


C. Coding - Correct Answer ✔️✔️What allows the diagnostic, treatment,

and response of information of the patient to be aggregated into a uniform data

set?


A. Physician documentation


B. Transcription


C. Coding


D. Clinical documentation improvement


D. Impression and plan - Correct Answer ✔️✔️What part of the health

record, usually located at the end the document, provides a complete picture of

the patient's diagnosis?


A. History and physical


B. Consultation reports


C. Assessment and exam

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