NURS 522 Advanced Health Assessment
Exam 1
List five general principles of documentation that are based on CMS guidelines. - ANSa. The
medical record should be complete and legible.
b. The documentation of each patient encounter should include the following:
• Reason for the encounter and relevant history, physical examination findings, and diagnostic
test results
• Assessment, clinical impression, or diagnosis
• Plan for care
• Date and legible identity of the health-care provider
c. If not documented, the rationale for ordering diagnostic and other ancillary services should be
easily inferred.
d. Past and present diagnoses should be accessible to the treating and consulting providers.
e. The patient's progress, response to and changes in treatment, and revision of diagnoses
should be documented.
In addition to other health-care providers, list five different types or groups of people who could
read medical records you create. - ANSa. Attorneys
b. Malpractice carriers
c. Jurors/Judges
d. Patients
e. CMS/JCAHO
Describe how to make a correction in a paper medical record. - ANSWhen 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? - ANSAcceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to
make a late entry in a chart or medical record? - ANSAcceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to
use correction fluid or tape to obliterate an entry in a record? - ANSUnacceptable
,Is it acceptable or unacceptable according to generally accepted documentation guidelines to
make an entry in a record before seeing a patient? - ANSAcceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to
alter an entry in a medical record? - ANSUnacceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to
stamp a record "signed but not read"? - ANSUnacceptable
True or False? CPT codes reflect the level of evaluation and management services provided. -
ANSFalse
True or False? The three key elements of determining the level of service are history, review of
systems, and physical examination. - ANSFalse
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. - ANSTrue
True or False? ICD codes indicate the reason for patient services. - ANSTrue
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. - ANSFalse
True or False? The medical record must include documentation that supports the assessment. -
ANSTrue
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. - ANSFalse
True or False? An ICD code should be as broad and encompassing as possible. - ANSFalse
True or False? There is no code for "rule out." - ANSTrue
True or False? The complexity of medical decision-making takes into account the number of
treatment options. - ANSTrue
ICD codes are used to identify what? - ANSPhysical exam findings, Reason for office visit,
Complaints, Diagnosis, Symptoms, Conditions
List five functions that an EMR system should be able to perform. - ANSHealth 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. - ANSAn 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.
b) Result management would ensure that all providers participating in the care of a patient
would have quick access to new and past test results, regardless of who ordered the tests, the
geographic location of the ordering provider, or when the tests were ordered or performed.
c) Order management would include the ability to enter and store orders for prescriptions, tests,
and other services in a computer-based system that would enhance legibility, reduce
duplication, reduce fragmentation, and improve the speed with which orders are executed.
d) Using reminders, prompts, and alerts, computerized decision-support systems would improve
compliance with best clinical practices, ensure regular screenings and other preventive
practices, identify possible drug-drug or drug-disease interactions, and facilitate diagnoses and
treatments.
e) Patients would be provided tools that give them access to their health records and interactive
patient education and that would help them carry out home-monitoring and self-testing to
improve control of chronic conditions.
Identify at least five potential barriers to implementing an EMR system. - ANSLimited computer
literacy on the part of providers
b) Concerns over security, productivity, patient satisfaction, and unreliable technology
c) Costs of hardware and software
d) Concerns about safety and security of systems and the ability to protect and keep private
confidential health information
e) Technical matters, such as functionality, ease of use, and customer support from vendors are
other barriers
List at least two criteria required to meet "meaningful use" standards. - ANSProviders have to
show that they are meeting certain measurement thresholds that range from recording patient
information as structured data to exchanging summary care records.
b) The HITECH Act imposes requirements for notification of a data breach related to
unauthorized uses and disclosures of "unsecured protected health information" (PHI).
True or False? HIPAA establishes standards for the electronic transfer of health data. - ANSTrue
True or False? Provides health care for everyone. - ANSFalse
True or False? Limits exclusion of pre-existing medical conditions to 24 months. - ANSFalse
True or False? Gives patients more access to their medical records. - ANSTrue
, True or False? Protects medical records from improper uses and disclosures. - ANSTrue
True or False? Federal HIPAA regulations pre-empt state laws. - ANSTrue
True or False? The Privacy Rule applies only to covered entities that transmit medical
information electronically. - ANSTrue
True or False? Protected Health Information is data that could be used to identify an individual. -
ANSTrue
True or False? Covered entities include doctors, clinics, dentists, nursing homes, chiropractors,
psychologists, pharmacies, and insurance companies. - ANSTrue
True or False? A covered entity may disclose PHI without patient authorization for purposes of
treatment, payment, or its health-care operations. - ANSTrue
True or False? PHI cannot be transmitted between covered entities by e-mail. - ANSFalse
True or False? Patients are entitled to a list of everyone with whom their health-care provider
has shared PHI. - ANSTrue
True or False? PHI may be disclosed to someone involved in the patient's health care without
written authorization. - ANSTrue
True or False? The Privacy Rule allows certain minors access to specified health care, such as
mental health counseling, without parental consent. - ANSFalse
True or False? A Notice of Privacy Practice explains how patients' PHI is used and disclosed. -
ANSTrue
True or False? An employee cannot be terminated for violating the Privacy Rule. - ANSFalse
True or False? An individual may not sue his or her insurance company over a HIPAA violation.
- ANSFalse
True or False? Criminal penalties for HIPAA violations can result in fines and imprisonment. -
ANSTrue
True or False? The confidentiality, integrity, and availability of PHI need to be protected only
when the PHI is transmitted, not when it is stored. - ANSFalse
True or false? Employees are required to attend periodic security awareness and training. -
ANSTrue
Exam 1
List five general principles of documentation that are based on CMS guidelines. - ANSa. The
medical record should be complete and legible.
b. The documentation of each patient encounter should include the following:
• Reason for the encounter and relevant history, physical examination findings, and diagnostic
test results
• Assessment, clinical impression, or diagnosis
• Plan for care
• Date and legible identity of the health-care provider
c. If not documented, the rationale for ordering diagnostic and other ancillary services should be
easily inferred.
d. Past and present diagnoses should be accessible to the treating and consulting providers.
e. The patient's progress, response to and changes in treatment, and revision of diagnoses
should be documented.
In addition to other health-care providers, list five different types or groups of people who could
read medical records you create. - ANSa. Attorneys
b. Malpractice carriers
c. Jurors/Judges
d. Patients
e. CMS/JCAHO
Describe how to make a correction in a paper medical record. - ANSWhen 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? - ANSAcceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to
make a late entry in a chart or medical record? - ANSAcceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to
use correction fluid or tape to obliterate an entry in a record? - ANSUnacceptable
,Is it acceptable or unacceptable according to generally accepted documentation guidelines to
make an entry in a record before seeing a patient? - ANSAcceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to
alter an entry in a medical record? - ANSUnacceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to
stamp a record "signed but not read"? - ANSUnacceptable
True or False? CPT codes reflect the level of evaluation and management services provided. -
ANSFalse
True or False? The three key elements of determining the level of service are history, review of
systems, and physical examination. - ANSFalse
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. - ANSTrue
True or False? ICD codes indicate the reason for patient services. - ANSTrue
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. - ANSFalse
True or False? The medical record must include documentation that supports the assessment. -
ANSTrue
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. - ANSFalse
True or False? An ICD code should be as broad and encompassing as possible. - ANSFalse
True or False? There is no code for "rule out." - ANSTrue
True or False? The complexity of medical decision-making takes into account the number of
treatment options. - ANSTrue
ICD codes are used to identify what? - ANSPhysical exam findings, Reason for office visit,
Complaints, Diagnosis, Symptoms, Conditions
List five functions that an EMR system should be able to perform. - ANSHealth 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. - ANSAn 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.
b) Result management would ensure that all providers participating in the care of a patient
would have quick access to new and past test results, regardless of who ordered the tests, the
geographic location of the ordering provider, or when the tests were ordered or performed.
c) Order management would include the ability to enter and store orders for prescriptions, tests,
and other services in a computer-based system that would enhance legibility, reduce
duplication, reduce fragmentation, and improve the speed with which orders are executed.
d) Using reminders, prompts, and alerts, computerized decision-support systems would improve
compliance with best clinical practices, ensure regular screenings and other preventive
practices, identify possible drug-drug or drug-disease interactions, and facilitate diagnoses and
treatments.
e) Patients would be provided tools that give them access to their health records and interactive
patient education and that would help them carry out home-monitoring and self-testing to
improve control of chronic conditions.
Identify at least five potential barriers to implementing an EMR system. - ANSLimited computer
literacy on the part of providers
b) Concerns over security, productivity, patient satisfaction, and unreliable technology
c) Costs of hardware and software
d) Concerns about safety and security of systems and the ability to protect and keep private
confidential health information
e) Technical matters, such as functionality, ease of use, and customer support from vendors are
other barriers
List at least two criteria required to meet "meaningful use" standards. - ANSProviders have to
show that they are meeting certain measurement thresholds that range from recording patient
information as structured data to exchanging summary care records.
b) The HITECH Act imposes requirements for notification of a data breach related to
unauthorized uses and disclosures of "unsecured protected health information" (PHI).
True or False? HIPAA establishes standards for the electronic transfer of health data. - ANSTrue
True or False? Provides health care for everyone. - ANSFalse
True or False? Limits exclusion of pre-existing medical conditions to 24 months. - ANSFalse
True or False? Gives patients more access to their medical records. - ANSTrue
, True or False? Protects medical records from improper uses and disclosures. - ANSTrue
True or False? Federal HIPAA regulations pre-empt state laws. - ANSTrue
True or False? The Privacy Rule applies only to covered entities that transmit medical
information electronically. - ANSTrue
True or False? Protected Health Information is data that could be used to identify an individual. -
ANSTrue
True or False? Covered entities include doctors, clinics, dentists, nursing homes, chiropractors,
psychologists, pharmacies, and insurance companies. - ANSTrue
True or False? A covered entity may disclose PHI without patient authorization for purposes of
treatment, payment, or its health-care operations. - ANSTrue
True or False? PHI cannot be transmitted between covered entities by e-mail. - ANSFalse
True or False? Patients are entitled to a list of everyone with whom their health-care provider
has shared PHI. - ANSTrue
True or False? PHI may be disclosed to someone involved in the patient's health care without
written authorization. - ANSTrue
True or False? The Privacy Rule allows certain minors access to specified health care, such as
mental health counseling, without parental consent. - ANSFalse
True or False? A Notice of Privacy Practice explains how patients' PHI is used and disclosed. -
ANSTrue
True or False? An employee cannot be terminated for violating the Privacy Rule. - ANSFalse
True or False? An individual may not sue his or her insurance company over a HIPAA violation.
- ANSFalse
True or False? Criminal penalties for HIPAA violations can result in fines and imprisonment. -
ANSTrue
True or False? The confidentiality, integrity, and availability of PHI need to be protected only
when the PHI is transmitted, not when it is stored. - ANSFalse
True or false? Employees are required to attend periodic security awareness and training. -
ANSTrue
