LEV3701 ACTUAL TEST PAPER FULL
QUESTIONS AND ACCURATE ANSWERS
GRADED APLUS
●● point-of-care documentation
Answer: The old practices of flagging records for deficiencies and
requiring retrospective documentation add little or no value to patient
care. You try to convince the entire health care team to consistently enter
data into the patient's record at the time and location of service instead
of waiting for retrospective analysis to alert them to complete the record.
You are proposing
●● impressions of a cardiologist asked to determine whether patient is a
good surgical risk
Answer: The Conditions of Participation requires that the medical staff
bylaws, rules, and regulations address the status of consultants. Which of
the following reports would normally be considered a consultation?
●● 24 hours after admission or prior to surgery.
Answer: You have been appointed as Chair of the Health Record
Committee at a new hospital. Your committee has been asked to
recommend time-limited documentation standards for inclusion in the
medical staff bylaws, rules, and regulations. The committee
documentation standards must meet the standards of both the Joint
Commission and the Medicare Conditions of Participation. The
,standards for the history and physical exam documentation are discussed
first. You advise them that the time period for completion of this report
should be set at
●● comprehensiveness
Answer: Using a template to collect data for key reports may help to
prompt caregivers to document all required data elements in the patient
record. This practice contributes to data
●● qualitative review
Answer: During a retrospective review of Rose Hunter's inpatient health
record, the health information clerk notes that on day 4 of hospitalization
there was one missed dose of insulin. What type of review is this clerk
performing?
●● auditor.
Answer: A major contribution to a successful CDI program is the ability
to demonstrate the impact that documentation has on data reporting to
the facility's staff. In this role, the Clinical Documentation specialist is
acting as a(n)
●● discrepancy between post-op diagnosis by the surgeon and pathology
diagnosis by the pathologist
Answer: Which of the following is least likely to be identified by a
retrospective quantitative analysis of a health record?
, ●● physical exam
Answer: Based on the following documentation in an acute care record,
where would you expect this excerpt to appear?
"The patient is alert and in no acute distress. Initial vital signs: T 98, P
102 and regular, R 20 and BP 120/69..."
●● Based on the following documentation in an acute care record, where
would you expect this excerpt to appear?
"With the patient in the supine position, the right side of the neck was
appropriately prepped with betadine solution and draped. I was able to
pass the central line, which was taped to skin and used for administration
of drugs during resuscitation."
Answer: operative record
●● The final HITECH Omnibus Rule expanded some of HIPAA's
original requirements, including changes in immunization disclosures.
As a result, where states require immunization records of a minor prior
to admitting a student to a school, a covered entity is permitted to
Answer: simply document a written or oral agreement from a parent or
guardian before releasing the immunization record to the school
QUESTIONS AND ACCURATE ANSWERS
GRADED APLUS
●● point-of-care documentation
Answer: The old practices of flagging records for deficiencies and
requiring retrospective documentation add little or no value to patient
care. You try to convince the entire health care team to consistently enter
data into the patient's record at the time and location of service instead
of waiting for retrospective analysis to alert them to complete the record.
You are proposing
●● impressions of a cardiologist asked to determine whether patient is a
good surgical risk
Answer: The Conditions of Participation requires that the medical staff
bylaws, rules, and regulations address the status of consultants. Which of
the following reports would normally be considered a consultation?
●● 24 hours after admission or prior to surgery.
Answer: You have been appointed as Chair of the Health Record
Committee at a new hospital. Your committee has been asked to
recommend time-limited documentation standards for inclusion in the
medical staff bylaws, rules, and regulations. The committee
documentation standards must meet the standards of both the Joint
Commission and the Medicare Conditions of Participation. The
,standards for the history and physical exam documentation are discussed
first. You advise them that the time period for completion of this report
should be set at
●● comprehensiveness
Answer: Using a template to collect data for key reports may help to
prompt caregivers to document all required data elements in the patient
record. This practice contributes to data
●● qualitative review
Answer: During a retrospective review of Rose Hunter's inpatient health
record, the health information clerk notes that on day 4 of hospitalization
there was one missed dose of insulin. What type of review is this clerk
performing?
●● auditor.
Answer: A major contribution to a successful CDI program is the ability
to demonstrate the impact that documentation has on data reporting to
the facility's staff. In this role, the Clinical Documentation specialist is
acting as a(n)
●● discrepancy between post-op diagnosis by the surgeon and pathology
diagnosis by the pathologist
Answer: Which of the following is least likely to be identified by a
retrospective quantitative analysis of a health record?
, ●● physical exam
Answer: Based on the following documentation in an acute care record,
where would you expect this excerpt to appear?
"The patient is alert and in no acute distress. Initial vital signs: T 98, P
102 and regular, R 20 and BP 120/69..."
●● Based on the following documentation in an acute care record, where
would you expect this excerpt to appear?
"With the patient in the supine position, the right side of the neck was
appropriately prepped with betadine solution and draped. I was able to
pass the central line, which was taped to skin and used for administration
of drugs during resuscitation."
Answer: operative record
●● The final HITECH Omnibus Rule expanded some of HIPAA's
original requirements, including changes in immunization disclosures.
As a result, where states require immunization records of a minor prior
to admitting a student to a school, a covered entity is permitted to
Answer: simply document a written or oral agreement from a parent or
guardian before releasing the immunization record to the school
