Guide to Clinical Documentation Ch. 1 ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
exam with correct answers ||\\||\\ ||\\||\\ ||\\||\\
In addition to other health-care providers, list five
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
different types or groups of people who could read ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
medical records you create. - correct answers ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
✔✔Attorneys
Patients
Judges
Health-care payers ||\\||\\
Researchers
List at least five general principles of documentation
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
that are based on CMS guidelines. - correct answers
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
✔✔1. Complete and legible ||\\||\\ ||\\||\\ ||\\||\\
2. Rationale for ordering diagnostic and other
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
ancillary services should be easily inferred. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
3. Past and present diagnoses
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
, 4. Appropriate health risk factors
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
5. Patient's progress, response to and changes in
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
treatment, and revision of diagnoses should be ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
documented
Ruled sheet (orders) should have no blank lines.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Describe how to make a correction in a paper ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
medical record. - correct answers ✔✔Alteration||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
connotes an improper change, concealment, or ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
omission of portions of records that were written ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
inappropriately. Correction implies the act of making ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
something right. Appropriate correction is ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
encouraged!
Paper record - draw a single line through the text,
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
initial and date the entry, and label it as an error. If
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
there is room, enter correct information. Do not use
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
margins. If there is not room, make an addendum. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
exam with correct answers ||\\||\\ ||\\||\\ ||\\||\\
In addition to other health-care providers, list five
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
different types or groups of people who could read ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
medical records you create. - correct answers ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
✔✔Attorneys
Patients
Judges
Health-care payers ||\\||\\
Researchers
List at least five general principles of documentation
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
that are based on CMS guidelines. - correct answers
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
✔✔1. Complete and legible ||\\||\\ ||\\||\\ ||\\||\\
2. Rationale for ordering diagnostic and other
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
ancillary services should be easily inferred. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
3. Past and present diagnoses
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
, 4. Appropriate health risk factors
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
5. Patient's progress, response to and changes in
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
treatment, and revision of diagnoses should be ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
documented
Ruled sheet (orders) should have no blank lines.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Describe how to make a correction in a paper ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
medical record. - correct answers ✔✔Alteration||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
connotes an improper change, concealment, or ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
omission of portions of records that were written ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
inappropriately. Correction implies the act of making ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
something right. Appropriate correction is ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
encouraged!
Paper record - draw a single line through the text,
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
initial and date the entry, and label it as an error. If
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
there is room, enter correct information. Do not use
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
margins. If there is not room, make an addendum. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
