CDEO - Chapter 2 Questions With Complete Solutions
1 Correct Answers Any system that would meet the
authentication requirements are as follows: Computerized
systems that require the physician to review the document on-
line and indicate that it has been approved by entering a
computer code. 2.) A system in which the physician signs off
against a list of entries that must be verified in the individual
record. 3.) A mail system in which transcripts are sent to the
physician for review, and then he or she signs and returns a
postcard identifying the record and verifying its accuracy.A
system of auto-authentication in which a physician or other
practitioner authenticates a report before transcription is not
consistent with these requirements. There must be a method of
determining the practitioner did, in fact, authenticate the
document after it was transcribed."
1, 2 Correct Answers The hospital must have a medical record
service that has administrative responsibility for medical
records. A medical record must be maintained for every
individual evaluated or treated in the hospital(a) Standard:
Organization and staffing. The organization of the medical
record service must be appropriate to the scope and complexity
of the services performed. The hospital must employ adequate
personnel to ensure prompt completion, filing, and retrieval of
records. (b) Standard: Form and retention of record. The hospital
must maintain a medical record for each inpatient and
outpatient.
100, 25,000 Correct Answers For violations occurring prior to
2/18/2009, the penalty amount is up to $___ per violation, with a
,calendar year cap of $_______. For violations occurring on or
after 2/18/2009, the penalty amount ranges from $100 to
$50,000 or more, per violation, with a calendar year cap of
$1,500,000.
12 Correct Answers The Privacy Rule permits use and
disclosure of this information without an individual's
authorization or permission through public interest and benefit
activities. There are 12 national priority purposes: Required by
law, Public health activities, Victims of abuse, neglect, or
domestic violence, Health oversight activities, Judicial and
administrative proceedings, Law enforcement purposes,
Decedents (Funeral directors or medical examiners), Cadaveric
organ, eye, or tissue donation, Research, Serious threat to health
or safety, Essential government functions, Workers'
compensation
A Correct Answers _____—Assessment
A—Assessment Correct Answers _______; the provider's
assessment of the patient's condition, and where the provider
indicates either a definitive or working diagnosis.
AAAHC Correct Answers In the past, the primary source for
accrediting standards in healthcare has been the JC. Medicare
now has additional organizations approved as Accreditation
Programs such as the Accreditation Association for Ambulatory
Health- care (AAAHC). A complete list can be found on the
Center for Medicare & Medicaid Services' (CMS) website.
,absence Correct Answers In the _____ of specific statute or
regulations, many healthcare institutions establish their own
standards or requirements in relation to the content of a medical
record.
accounting Correct Answers Maintain and make available the
information required to provide an _____ of disclosures to the
[Choose either "covered entity" or "individual"] as necessary to
satisfy covered entity's obligations under 45 CFR 164.528;
Accreditation Association for Ambulatory Health Care Correct
Answers AAAHC
accredited Correct Answers To be ______ by HSS for
Medicare and the JC, the following medical record requirements
must be in place for all patients: Admission report, Consent to
treatment form, Attestation statement, Medical history,
Physician's orders, Report of physical examination, Progress
notes, Pathology reports, Radiology reports, Consultation
reports, Anesthesia record, Operative report, Nurse's notes, Vital
signs graphics, Medication sheet, Laboratory report, Physical
therapy evaluation, Respiratory therapy evaluation, Special
reports (Obstetrics, nursery), Discharge reports
Accrediting Correct Answers _____ standards are not laws,
but guidelines used to establish the standard of care in
negligence actions against healthcare provider which is why it is
extremely important that healthcare providers closely follow the
standards of accreditation.
, accurate Correct Answers The hospital must have a method to
require that each author takes a specific action to verify that the
entry being authenticated is his order entry or that he or she is
responsible for the entry, and that the entry is ______.
accurate Correct Answers The hospital must have a method to
require that each author takes a specific action to verify that the
entry being authenticated is his orher entry or that he or she is
respon- sible for the entry, and that the entry is ______
Acronyms Correct Answers _____ are acceptable in the
medical record if they are commonly recognized. When
auditing, it is common to come across use of abbreviations that
are not industry standard. If a practice uses abbreviations that
are not industry standard, they must maintain a list of the
abbreviations with definitions and how they are used and should
understand that documentation should be submitted anytime an
audit is done.
acronyms, abbreviations Correct Answers Many medical
records contain _____ and ______ understood by the general
medical community.
action Correct Answers There must be a specific _____ by the
author to indicate that the entry is verified and accurate.
Additional optional, but recommended, elements for a plan of
care include: l Short term goals; l Goals and duration for the
current episode of care; l Specific treatment interventions,
procedures, modalities, or techniques and the amount of each; l
Beginning date for the plan. Correct Answers
1 Correct Answers Any system that would meet the
authentication requirements are as follows: Computerized
systems that require the physician to review the document on-
line and indicate that it has been approved by entering a
computer code. 2.) A system in which the physician signs off
against a list of entries that must be verified in the individual
record. 3.) A mail system in which transcripts are sent to the
physician for review, and then he or she signs and returns a
postcard identifying the record and verifying its accuracy.A
system of auto-authentication in which a physician or other
practitioner authenticates a report before transcription is not
consistent with these requirements. There must be a method of
determining the practitioner did, in fact, authenticate the
document after it was transcribed."
1, 2 Correct Answers The hospital must have a medical record
service that has administrative responsibility for medical
records. A medical record must be maintained for every
individual evaluated or treated in the hospital(a) Standard:
Organization and staffing. The organization of the medical
record service must be appropriate to the scope and complexity
of the services performed. The hospital must employ adequate
personnel to ensure prompt completion, filing, and retrieval of
records. (b) Standard: Form and retention of record. The hospital
must maintain a medical record for each inpatient and
outpatient.
100, 25,000 Correct Answers For violations occurring prior to
2/18/2009, the penalty amount is up to $___ per violation, with a
,calendar year cap of $_______. For violations occurring on or
after 2/18/2009, the penalty amount ranges from $100 to
$50,000 or more, per violation, with a calendar year cap of
$1,500,000.
12 Correct Answers The Privacy Rule permits use and
disclosure of this information without an individual's
authorization or permission through public interest and benefit
activities. There are 12 national priority purposes: Required by
law, Public health activities, Victims of abuse, neglect, or
domestic violence, Health oversight activities, Judicial and
administrative proceedings, Law enforcement purposes,
Decedents (Funeral directors or medical examiners), Cadaveric
organ, eye, or tissue donation, Research, Serious threat to health
or safety, Essential government functions, Workers'
compensation
A Correct Answers _____—Assessment
A—Assessment Correct Answers _______; the provider's
assessment of the patient's condition, and where the provider
indicates either a definitive or working diagnosis.
AAAHC Correct Answers In the past, the primary source for
accrediting standards in healthcare has been the JC. Medicare
now has additional organizations approved as Accreditation
Programs such as the Accreditation Association for Ambulatory
Health- care (AAAHC). A complete list can be found on the
Center for Medicare & Medicaid Services' (CMS) website.
,absence Correct Answers In the _____ of specific statute or
regulations, many healthcare institutions establish their own
standards or requirements in relation to the content of a medical
record.
accounting Correct Answers Maintain and make available the
information required to provide an _____ of disclosures to the
[Choose either "covered entity" or "individual"] as necessary to
satisfy covered entity's obligations under 45 CFR 164.528;
Accreditation Association for Ambulatory Health Care Correct
Answers AAAHC
accredited Correct Answers To be ______ by HSS for
Medicare and the JC, the following medical record requirements
must be in place for all patients: Admission report, Consent to
treatment form, Attestation statement, Medical history,
Physician's orders, Report of physical examination, Progress
notes, Pathology reports, Radiology reports, Consultation
reports, Anesthesia record, Operative report, Nurse's notes, Vital
signs graphics, Medication sheet, Laboratory report, Physical
therapy evaluation, Respiratory therapy evaluation, Special
reports (Obstetrics, nursery), Discharge reports
Accrediting Correct Answers _____ standards are not laws,
but guidelines used to establish the standard of care in
negligence actions against healthcare provider which is why it is
extremely important that healthcare providers closely follow the
standards of accreditation.
, accurate Correct Answers The hospital must have a method to
require that each author takes a specific action to verify that the
entry being authenticated is his order entry or that he or she is
responsible for the entry, and that the entry is ______.
accurate Correct Answers The hospital must have a method to
require that each author takes a specific action to verify that the
entry being authenticated is his orher entry or that he or she is
respon- sible for the entry, and that the entry is ______
Acronyms Correct Answers _____ are acceptable in the
medical record if they are commonly recognized. When
auditing, it is common to come across use of abbreviations that
are not industry standard. If a practice uses abbreviations that
are not industry standard, they must maintain a list of the
abbreviations with definitions and how they are used and should
understand that documentation should be submitted anytime an
audit is done.
acronyms, abbreviations Correct Answers Many medical
records contain _____ and ______ understood by the general
medical community.
action Correct Answers There must be a specific _____ by the
author to indicate that the entry is verified and accurate.
Additional optional, but recommended, elements for a plan of
care include: l Short term goals; l Goals and duration for the
current episode of care; l Specific treatment interventions,
procedures, modalities, or techniques and the amount of each; l
Beginning date for the plan. Correct Answers
