NURS 522 ADVANCED HEALTH ASSESSMENT
EXAM 1 WITH ALL CORRECT & VERIFIED
ANSWERS (UPDATED TO PASS)
List five general principles of documentation that are based on CMS guidelines. Correct answer-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.
In addition to other health-care providers, list five different types or groups of people who could read
medical records you create. Correct answer-a. Attorneys
b. Malpractice carriers
c. Jurors/Judges
d. Patients
e. CMS/JCAHO
Describe how to make a correction in a paper medical record. Correct answer-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.
Is it acceptable or unacceptable according to generally accepted documentation guidelines to use
either of the 1995 or 1997 CMS guidelines? Correct answer-Acceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to make a
late entry in a chart or medical record? Correct answer-Acceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to use
correction fluid or tape to obliterate an entry in a record? Correct answer-Unacceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to make
an entry in a record before seeing a patient? Correct answer-Acceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to alter
an entry in a medical record? Correct answer-Unacceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to stamp
a record "signed but not read"? Correct answer-Unacceptable
,True or False? CPT codes reflect the level of evaluation and management services provided.
Correct answer-False
True or False? The three key elements of determining the level of service are history, review of
systems, and physical examination. Correct answer-False
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. Correct answer-True
True or False? ICD codes indicate the reason for patient services. Correct answer-True
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. Correct answer-False
True or False? The medical record must include documentation that supports the assessment.
Correct answer-True
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.
Correct answer-False
True or False? An ICD code should be as broad and encompassing as possible. Correct answer-False
True or False? There is no code for "rule out." Correct answer-True
True or False? The complexity of medical decision-making takes into account the number of
treatment options. Correct answer-True
ICD codes are used to identify what? Correct answer-Physical exam findings, Reason for office visit,
Complaints, Diagnosis, Symptoms, Conditions
List five functions that an EMR system should be able to perform. Correct answer-Health
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. Correct answer-An 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. Correct answer-Limited
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. Correct answer-Providers
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. Correct
answer-True
True or False? Provides health care for everyone. Correct answer-False
True or False? Limits exclusion of pre-existing medical conditions to 24 months. Correct answer-
False
True or False? Gives patients more access to their medical records. Correct answer-True
True or False? Protects medical records from improper uses and disclosures. Correct answer-True
True or False? Federal HIPAA regulations pre-empt state laws. Correct answer-True
True or False? The Privacy Rule applies only to covered entities that transmit medical information
electronically. Correct answer-True
True or False? Protected Health Information is data that could be used to identify an individual.
Correct answer-True
True or False? Covered entities include doctors, clinics, dentists, nursing homes, chiropractors,
psychologists, pharmacies, and insurance companies. Correct answer-True
True or False? A covered entity may disclose PHI without patient authorization for purposes of
treatment, payment, or its health-care operations. Correct answer-True
True or False? PHI cannot be transmitted between covered entities by e-mail. Correct answer-False
True or False? Patients are entitled to a list of everyone with whom their health-care provider has
shared PHI. Correct answer-True
, True or False? PHI may be disclosed to someone involved in the patient's health care without written
authorization. Correct answer-True
True or False? The Privacy Rule allows certain minors access to specified health care, such as mental
health counseling, without parental consent. Correct answer-False
True or False? A Notice of Privacy Practice explains how patients' PHI is used and disclosed. Correct
answer-True
True or False? An employee cannot be terminated for violating the Privacy Rule. Correct answer-
False
True or False? An individual may not sue his or her insurance company over a HIPAA violation.
Correct answer-False
True or False? Criminal penalties for HIPAA violations can result in fines and imprisonment. Correct
answer-True
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. Correct answer-False
True or false? Employees are required to attend periodic security awareness and training. Correct
answer-True
True or False? The Security Rule requires covered entities to install and regularly update antivirus,
anti-spyware, and firewall software. Correct answer-True
True or False? Physical and technical safeguards must be in place to prevent PHI from being
transmitted over the Internet. Correct answer-True
True or False? HIPAA requires a process to develop contracts with business associates that will ensure
they will safeguard PHI. Correct answer-True
True or False? HIPAA may not audit a practice for compliance without notice. Correct answer-False
List 5 entities that would be considered a covered entity according to HIPAA. Correct answer-
chiropractor
social worker
psychologist
nurse practitioner
medical assistant
nursing home doctor
HMO
PPO
Affairs (VA) hospital
Medicaid
Identify at least two conditions that are considered sensitive PHI. Correct answer-a) HIV
b) Substance abuse
EXAM 1 WITH ALL CORRECT & VERIFIED
ANSWERS (UPDATED TO PASS)
List five general principles of documentation that are based on CMS guidelines. Correct answer-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.
In addition to other health-care providers, list five different types or groups of people who could read
medical records you create. Correct answer-a. Attorneys
b. Malpractice carriers
c. Jurors/Judges
d. Patients
e. CMS/JCAHO
Describe how to make a correction in a paper medical record. Correct answer-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.
Is it acceptable or unacceptable according to generally accepted documentation guidelines to use
either of the 1995 or 1997 CMS guidelines? Correct answer-Acceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to make a
late entry in a chart or medical record? Correct answer-Acceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to use
correction fluid or tape to obliterate an entry in a record? Correct answer-Unacceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to make
an entry in a record before seeing a patient? Correct answer-Acceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to alter
an entry in a medical record? Correct answer-Unacceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to stamp
a record "signed but not read"? Correct answer-Unacceptable
,True or False? CPT codes reflect the level of evaluation and management services provided.
Correct answer-False
True or False? The three key elements of determining the level of service are history, review of
systems, and physical examination. Correct answer-False
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. Correct answer-True
True or False? ICD codes indicate the reason for patient services. Correct answer-True
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. Correct answer-False
True or False? The medical record must include documentation that supports the assessment.
Correct answer-True
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.
Correct answer-False
True or False? An ICD code should be as broad and encompassing as possible. Correct answer-False
True or False? There is no code for "rule out." Correct answer-True
True or False? The complexity of medical decision-making takes into account the number of
treatment options. Correct answer-True
ICD codes are used to identify what? Correct answer-Physical exam findings, Reason for office visit,
Complaints, Diagnosis, Symptoms, Conditions
List five functions that an EMR system should be able to perform. Correct answer-Health
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. Correct answer-An 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. Correct answer-Limited
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. Correct answer-Providers
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. Correct
answer-True
True or False? Provides health care for everyone. Correct answer-False
True or False? Limits exclusion of pre-existing medical conditions to 24 months. Correct answer-
False
True or False? Gives patients more access to their medical records. Correct answer-True
True or False? Protects medical records from improper uses and disclosures. Correct answer-True
True or False? Federal HIPAA regulations pre-empt state laws. Correct answer-True
True or False? The Privacy Rule applies only to covered entities that transmit medical information
electronically. Correct answer-True
True or False? Protected Health Information is data that could be used to identify an individual.
Correct answer-True
True or False? Covered entities include doctors, clinics, dentists, nursing homes, chiropractors,
psychologists, pharmacies, and insurance companies. Correct answer-True
True or False? A covered entity may disclose PHI without patient authorization for purposes of
treatment, payment, or its health-care operations. Correct answer-True
True or False? PHI cannot be transmitted between covered entities by e-mail. Correct answer-False
True or False? Patients are entitled to a list of everyone with whom their health-care provider has
shared PHI. Correct answer-True
, True or False? PHI may be disclosed to someone involved in the patient's health care without written
authorization. Correct answer-True
True or False? The Privacy Rule allows certain minors access to specified health care, such as mental
health counseling, without parental consent. Correct answer-False
True or False? A Notice of Privacy Practice explains how patients' PHI is used and disclosed. Correct
answer-True
True or False? An employee cannot be terminated for violating the Privacy Rule. Correct answer-
False
True or False? An individual may not sue his or her insurance company over a HIPAA violation.
Correct answer-False
True or False? Criminal penalties for HIPAA violations can result in fines and imprisonment. Correct
answer-True
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. Correct answer-False
True or false? Employees are required to attend periodic security awareness and training. Correct
answer-True
True or False? The Security Rule requires covered entities to install and regularly update antivirus,
anti-spyware, and firewall software. Correct answer-True
True or False? Physical and technical safeguards must be in place to prevent PHI from being
transmitted over the Internet. Correct answer-True
True or False? HIPAA requires a process to develop contracts with business associates that will ensure
they will safeguard PHI. Correct answer-True
True or False? HIPAA may not audit a practice for compliance without notice. Correct answer-False
List 5 entities that would be considered a covered entity according to HIPAA. Correct answer-
chiropractor
social worker
psychologist
nurse practitioner
medical assistant
nursing home doctor
HMO
PPO
Affairs (VA) hospital
Medicaid
Identify at least two conditions that are considered sensitive PHI. Correct answer-a) HIV
b) Substance abuse
