REGULATORY COMPLIANCE
QUESTIONS AND ANSWERS WITH
SOLUTIONS 2024
70. Most hospitals require a medical record to be completed within:
a. 5 days
b. 10 days
c. 7 days
d. 30 days - ANSWER d
71. To correct an entry in a paper-based medical record, the provider should:
a. Draw a single line through the error, add a note explaining the error, initial and date, add the correct
information in chronological order
b. Draw a double line through the error, initial and date, add the reason for the correction
c. Draw a single line through the error, and add the correct information in chronological order
d. Draw several lines through the error, obliterate the documentation as much as possible, initial and
date, add the correct information in chronological order - ANSWER a
72. After a patient is discharged from the hospital, the medical record must be reviewed for:
a. Inclusion of all incident reports
b. Certain basic reports (for example, history and physical, discharge summary, etc.)
c. Voided prescription pads
d. Personal case notes from all mental health providers - ANSWER b
73. A completed and signed operative report needs clarification of the size of the skin lesions that were
removed. What process is used for that clarification?
a. Amendment
b. Addendum
c. Update
d. Revision - ANSWER a
, 77. Which of the following would be considered a hospital-acquired condition when the POA indicator is
N?
a. DVT following a gastric procedure
b. Diabetes with neuropathy
c. Catheter-associated urinary tract infection
d. Foreign body in the thumb - ANSWER c
79. When a POA indicator for a HAC that is the only CC/MCC condition on the record is listed as N, what
happens to the reimbursement for that account?
a. Nothing, the reimbursement is not impacted as this is an internal quality monitoring code
b. The reimbursement goes up since the condition was not present on admission and more resources
were needed to care for the patient
c. The reimbursement goes down since the condition was not present on admission and could/should
have been prevented using best practices
d. The reimbursement is placed on hold until the physician clarifies why the patient did not have the
condition on admission - ANSWER c
80. Which of the following may be considered a hospital-acquired condition?
a. Diabetic foot ulcer
b. Stage 2 coccyx pressure ulcer
c. Calf ulcer, left leg, with muscle necrosis
d. Right elbow pressure ulcer, stage 4 - ANSWER d
81. Which of the following statements best describes how the retention of records should be
determined?
a. Unless state law requires longer periods of time, specific patient health information should be
retained for HIPAA established minimum time periods.
b. AHIMA has published specific guidelines for retention of health information and these guidelines
should be followed for records retention.
c. The Joint Commission has developed standards for retention of health information which must be
followed to maintain accreditation and these standards should be adhered to with regard to time
frames.
QUESTIONS AND ANSWERS WITH
SOLUTIONS 2024
70. Most hospitals require a medical record to be completed within:
a. 5 days
b. 10 days
c. 7 days
d. 30 days - ANSWER d
71. To correct an entry in a paper-based medical record, the provider should:
a. Draw a single line through the error, add a note explaining the error, initial and date, add the correct
information in chronological order
b. Draw a double line through the error, initial and date, add the reason for the correction
c. Draw a single line through the error, and add the correct information in chronological order
d. Draw several lines through the error, obliterate the documentation as much as possible, initial and
date, add the correct information in chronological order - ANSWER a
72. After a patient is discharged from the hospital, the medical record must be reviewed for:
a. Inclusion of all incident reports
b. Certain basic reports (for example, history and physical, discharge summary, etc.)
c. Voided prescription pads
d. Personal case notes from all mental health providers - ANSWER b
73. A completed and signed operative report needs clarification of the size of the skin lesions that were
removed. What process is used for that clarification?
a. Amendment
b. Addendum
c. Update
d. Revision - ANSWER a
, 77. Which of the following would be considered a hospital-acquired condition when the POA indicator is
N?
a. DVT following a gastric procedure
b. Diabetes with neuropathy
c. Catheter-associated urinary tract infection
d. Foreign body in the thumb - ANSWER c
79. When a POA indicator for a HAC that is the only CC/MCC condition on the record is listed as N, what
happens to the reimbursement for that account?
a. Nothing, the reimbursement is not impacted as this is an internal quality monitoring code
b. The reimbursement goes up since the condition was not present on admission and more resources
were needed to care for the patient
c. The reimbursement goes down since the condition was not present on admission and could/should
have been prevented using best practices
d. The reimbursement is placed on hold until the physician clarifies why the patient did not have the
condition on admission - ANSWER c
80. Which of the following may be considered a hospital-acquired condition?
a. Diabetic foot ulcer
b. Stage 2 coccyx pressure ulcer
c. Calf ulcer, left leg, with muscle necrosis
d. Right elbow pressure ulcer, stage 4 - ANSWER d
81. Which of the following statements best describes how the retention of records should be
determined?
a. Unless state law requires longer periods of time, specific patient health information should be
retained for HIPAA established minimum time periods.
b. AHIMA has published specific guidelines for retention of health information and these guidelines
should be followed for records retention.
c. The Joint Commission has developed standards for retention of health information which must be
followed to maintain accreditation and these standards should be adhered to with regard to time
frames.
