NURS 522 Advanced Health Assessment Exam 1
Questions and Correct Detailed Answers (Verified
Answers) ||Already Graded A+||Newest Version
Quiz: List five general principles of documentation that are based on CMS
guidelines.
Ans: a. 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.
Quiz: In addition to other health-care providers, list five different types or
groups of people who could read medical records you create.
o
o
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, Ans: a. Attorneys
b. Malpractice carriers
c. Jurors/Judges
d. Patients
e. CMS/JCAHO
Quiz: Describe how to make a correction in a paper medical record.
Ans: When 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.
Quiz: Is it acceptable or unacceptable according to generally accepted
documentation guidelines to use either of the 1995 or 1997 CMS guidelines?
Ans: Acceptable
Quiz: Is it acceptable or unacceptable according to generally accepted
documentation guidelines to make a late entry in a chart or medical record?
o
o
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, Ans: Acceptable
Quiz: Is it acceptable or unacceptable according to generally accepted
documentation guidelines to use correction fluid or tape to obliterate an entry
in a record?
Ans: Unacceptable
Quiz: Is it acceptable or unacceptable according to generally accepted
documentation guidelines to make an entry in a record before seeing a patient?
Ans: Acceptable
Quiz: Is it acceptable or unacceptable according to generally accepted
documentation guidelines to alter an entry in a medical record?
Ans: Unacceptable
Quiz: Is it acceptable or unacceptable according to generally accepted
documentation guidelines to stamp a record "signed but not read"?
Ans: Unacceptable
o
o
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, Quiz: True or False? CPT codes reflect the level of evaluation and
management services provided.
Ans: False
Quiz: True or False? The three key elements of determining the level of
service are history, review of systems, and physical examination.
Ans: False
Quiz: 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.
Ans: True
Quiz: True or False? ICD codes indicate the reason for patient services.
Ans: True
o
o
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me in the number given.
Questions and Correct Detailed Answers (Verified
Answers) ||Already Graded A+||Newest Version
Quiz: List five general principles of documentation that are based on CMS
guidelines.
Ans: a. 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.
Quiz: In addition to other health-care providers, list five different types or
groups of people who could read medical records you create.
o
o
© 2025 TestTrackers
WhatsApp or call o Resources & Updates: [Testtrackers - Stuvia US]
o Your Success is Our Mission!
[+254707240657]
o For online exams and tutor expert, please whatsapp
me in the number given.
, Ans: a. Attorneys
b. Malpractice carriers
c. Jurors/Judges
d. Patients
e. CMS/JCAHO
Quiz: Describe how to make a correction in a paper medical record.
Ans: When 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.
Quiz: Is it acceptable or unacceptable according to generally accepted
documentation guidelines to use either of the 1995 or 1997 CMS guidelines?
Ans: Acceptable
Quiz: Is it acceptable or unacceptable according to generally accepted
documentation guidelines to make a late entry in a chart or medical record?
o
o
© 2025 TestTrackers
WhatsApp or call o Resources & Updates: [Testtrackers - Stuvia US]
o Your Success is Our Mission!
[+254707240657]
o For online exams and tutor expert, please whatsapp
me in the number given.
, Ans: Acceptable
Quiz: Is it acceptable or unacceptable according to generally accepted
documentation guidelines to use correction fluid or tape to obliterate an entry
in a record?
Ans: Unacceptable
Quiz: Is it acceptable or unacceptable according to generally accepted
documentation guidelines to make an entry in a record before seeing a patient?
Ans: Acceptable
Quiz: Is it acceptable or unacceptable according to generally accepted
documentation guidelines to alter an entry in a medical record?
Ans: Unacceptable
Quiz: Is it acceptable or unacceptable according to generally accepted
documentation guidelines to stamp a record "signed but not read"?
Ans: Unacceptable
o
o
© 2025 TestTrackers
WhatsApp or call o Resources & Updates: [Testtrackers - Stuvia US]
o Your Success is Our Mission!
[+254707240657]
o For online exams and tutor expert, please whatsapp
me in the number given.
, Quiz: True or False? CPT codes reflect the level of evaluation and
management services provided.
Ans: False
Quiz: True or False? The three key elements of determining the level of
service are history, review of systems, and physical examination.
Ans: False
Quiz: 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.
Ans: True
Quiz: True or False? ICD codes indicate the reason for patient services.
Ans: True
o
o
© 2025 TestTrackers
WhatsApp or call o Resources & Updates: [Testtrackers - Stuvia US]
o Your Success is Our Mission!
[+254707240657]
o For online exams and tutor expert, please whatsapp
me in the number given.
