NURS 522 Advanced Health Assessment Exam 1 EXAM LATEST (2025) CO
PLETE QUESTIONS With 100% Verified Solutions,
Study online at https://quizlet.com/_hh1spr
a. The medical record should be com-
plete and legible.
b. The documentation of each patient en-
counter should include the following:
• Reason for the encounter and rele-
vant history, physical examination find-
ings, and diagnostic test results
• Assessment, clinical impression, or di-
agnosis
• Plan for care
List five general principles of documen-
• Date and legible identity of the
tation that are based on CMS guidelines.
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.
a. Attorneys
In addition to other health-care
b. Malpractice carriers
providers, list five different types or
c. Jurors/Judges
groups of people who could read medical
d. Patients
records you create.
e. CMS/JCAHO
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
Describe how to make a correction in a error. If there is room, you may enter the
paper medical record. 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 obliter-
, NURS 522 Advanced Health Assessment Exam 1 EXAM LATEST (2025) CO
PLETE QUESTIONS With 100% Verified Solutions,
Study online at https://quizlet.com/_hh1spr
ate an original note, nor should you use
correction fluid or tape.
Is it acceptable or unacceptable accord-
ing to generally accepted documentation
Acceptable
guidelines to use either of the 1995 or
1997 CMS guidelines?
Is it acceptable or unacceptable accord-
ing to generally accepted documentation
Acceptable
guidelines to make a late entry in a chart
or medical record?
Is it acceptable or unacceptable accord-
ing to generally accepted documentation
Unacceptable
guidelines to use correction fluid or tape
to obliterate an entry in a record?
Is it acceptable or unacceptable accord-
ing to generally accepted documentation
Acceptable
guidelines to make an entry in a record
before seeing a patient?
Is it acceptable or unacceptable accord-
ing to generally accepted documentation
Unacceptable
guidelines to alter an entry in a medical
record?
Is it acceptable or unacceptable accord-
ing to generally accepted documentation
Unacceptable
guidelines to stamp a record "signed but
not read"?
True or False? CPT codes reflect the
level of evaluation and management ser- False
vices provided.
True or False? The three key elements
of determining the level of service are
False
history, review of systems, and physical
examination.
True or False? Time spent counseling
the patient and the nature of the present-
, NURS 522 Advanced Health Assessment Exam 1 EXAM LATEST (2025) CO
PLETE QUESTIONS With 100% Verified Solutions,
Study online at https://quizlet.com/_hh1spr
ing problem are two factors that affect the
True
level of service provided.
True or False? ICD codes indicate the
True
reason for patient services.
True or False? The ICD-10 code set has
more than 155,000 codes, but it does not
False
have the capacity to accommodate new
diagnoses and procedures.
True or False? The medical record must
include documentation that supports the True
assessment.
True or False? Assignment of appropri-
ate CPT and ICD codes that support the
level of E/M services provided is depen- False
dent only on adequate documentation of
the history and physical examination.
True or False? An ICD code should be as
False
broad and encompassing as possible.
True or False? There is no code for "rule
True
out."
True or False? The complexity of medical
decision-making takes into account the True
number of treatment options.
Physical exam findings, Reason for office
ICD codes are used to identify what? visit, Complaints, Diagnosis, Symptoms,
Conditions
Health information and data
b) Result management
List five functions that an EMR system c) Order management
should be able to perform. d) Decision support
e) Electronic communication and con-
nectivity
Identify five perceived benefits of an
EMR system.
, NURS 522 Advanced Health Assessment Exam 1 EXAM LATEST (2025) CO
PLETE QUESTIONS With 100% Verified Solutions,
Study online at https://quizlet.com/_hh1spr
An electronic system would provide im-
mediate 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 man-
ner.
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 pre-
scriptions, tests, and other services in a
computer-based system that would en-
hance legibility, reduce duplication, re-
duce 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 clin-
ical practices, ensure regular screenings
and other preventive practices, identify
possible drug-drug or drug-disease in-
teractions, and facilitate diagnoses and
treatments.
e) Patients would be provided tools
that give them access to their health
records and interactive patient educa-
tion and that would help them carry out
home-monitoring and self-testing to im-
prove control of chronic conditions.
Identify at least five potential barriers to
implementing an EMR system.
PLETE QUESTIONS With 100% Verified Solutions,
Study online at https://quizlet.com/_hh1spr
a. The medical record should be com-
plete and legible.
b. The documentation of each patient en-
counter should include the following:
• Reason for the encounter and rele-
vant history, physical examination find-
ings, and diagnostic test results
• Assessment, clinical impression, or di-
agnosis
• Plan for care
List five general principles of documen-
• Date and legible identity of the
tation that are based on CMS guidelines.
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.
a. Attorneys
In addition to other health-care
b. Malpractice carriers
providers, list five different types or
c. Jurors/Judges
groups of people who could read medical
d. Patients
records you create.
e. CMS/JCAHO
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
Describe how to make a correction in a error. If there is room, you may enter the
paper medical record. 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 obliter-
, NURS 522 Advanced Health Assessment Exam 1 EXAM LATEST (2025) CO
PLETE QUESTIONS With 100% Verified Solutions,
Study online at https://quizlet.com/_hh1spr
ate an original note, nor should you use
correction fluid or tape.
Is it acceptable or unacceptable accord-
ing to generally accepted documentation
Acceptable
guidelines to use either of the 1995 or
1997 CMS guidelines?
Is it acceptable or unacceptable accord-
ing to generally accepted documentation
Acceptable
guidelines to make a late entry in a chart
or medical record?
Is it acceptable or unacceptable accord-
ing to generally accepted documentation
Unacceptable
guidelines to use correction fluid or tape
to obliterate an entry in a record?
Is it acceptable or unacceptable accord-
ing to generally accepted documentation
Acceptable
guidelines to make an entry in a record
before seeing a patient?
Is it acceptable or unacceptable accord-
ing to generally accepted documentation
Unacceptable
guidelines to alter an entry in a medical
record?
Is it acceptable or unacceptable accord-
ing to generally accepted documentation
Unacceptable
guidelines to stamp a record "signed but
not read"?
True or False? CPT codes reflect the
level of evaluation and management ser- False
vices provided.
True or False? The three key elements
of determining the level of service are
False
history, review of systems, and physical
examination.
True or False? Time spent counseling
the patient and the nature of the present-
, NURS 522 Advanced Health Assessment Exam 1 EXAM LATEST (2025) CO
PLETE QUESTIONS With 100% Verified Solutions,
Study online at https://quizlet.com/_hh1spr
ing problem are two factors that affect the
True
level of service provided.
True or False? ICD codes indicate the
True
reason for patient services.
True or False? The ICD-10 code set has
more than 155,000 codes, but it does not
False
have the capacity to accommodate new
diagnoses and procedures.
True or False? The medical record must
include documentation that supports the True
assessment.
True or False? Assignment of appropri-
ate CPT and ICD codes that support the
level of E/M services provided is depen- False
dent only on adequate documentation of
the history and physical examination.
True or False? An ICD code should be as
False
broad and encompassing as possible.
True or False? There is no code for "rule
True
out."
True or False? The complexity of medical
decision-making takes into account the True
number of treatment options.
Physical exam findings, Reason for office
ICD codes are used to identify what? visit, Complaints, Diagnosis, Symptoms,
Conditions
Health information and data
b) Result management
List five functions that an EMR system c) Order management
should be able to perform. d) Decision support
e) Electronic communication and con-
nectivity
Identify five perceived benefits of an
EMR system.
, NURS 522 Advanced Health Assessment Exam 1 EXAM LATEST (2025) CO
PLETE QUESTIONS With 100% Verified Solutions,
Study online at https://quizlet.com/_hh1spr
An electronic system would provide im-
mediate 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 man-
ner.
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 pre-
scriptions, tests, and other services in a
computer-based system that would en-
hance legibility, reduce duplication, re-
duce 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 clin-
ical practices, ensure regular screenings
and other preventive practices, identify
possible drug-drug or drug-disease in-
teractions, and facilitate diagnoses and
treatments.
e) Patients would be provided tools
that give them access to their health
records and interactive patient educa-
tion and that would help them carry out
home-monitoring and self-testing to im-
prove control of chronic conditions.
Identify at least five potential barriers to
implementing an EMR system.
