NURS 522 ADVANCED HEALTH
ASSESSMENT EXAM 1 2026/2027
WITH OVER 200 QUESTIONS AND
CORRECT ANSWERS RATED A+
Describe how to make a correction in a paper medical record.
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?
Acceptable
Is it acceptable or unacceptable according to generally accepted documentation
guidelines to make a late entry in a chart or medical record?
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?
Unacceptable
Is it acceptable or unacceptable according to generally accepted documentation
guidelines to make an entry in a record before seeing a patient?
Acceptable
Is it acceptable or unacceptable according to generally accepted documentation
guidelines to alter an entry in a medical record?
Unacceptable
,Is it acceptable or unacceptable according to generally accepted documentation
guidelines to stamp a record "signed but not read"?
Unacceptable
List five general principles of documentation that are based on CMS guidelines.
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.
a. Attorneys
b. Malpractice carriers
c. Jurors/Judges
d. Patients
e. CMS/JCAHO
True or False? CPT codes reflect the level of evaluation and management services
provided.
False
True or False? The three key elements of determining the level of service are
history, review of systems, and physical examination.
,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.
True
True or False? ICD codes indicate the reason for patient services.
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.
False
True or False? The medical record must include documentation that supports the
assessment.
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.
False
True or False? An ICD code should be as broad and encompassing as possible.
False
True or False? There is no code for "rule out."
True
True or False? Federal HIPAA regulations pre-empt state laws.
True
True or False? The Privacy Rule applies only to covered entities that transmit
medical information electronically.
True
, True or False? Protected Health Information is data that could be used to identify
an individual.
True
True or False? Covered entities include doctors, clinics, dentists, nursing homes,
chiropractors, psychologists, pharmacies, and insurance companies.
True
True or False? A covered entity may disclose PHI without patient authorization for
purposes of treatment, payment, or its health-care operations.
True
True or False? PHI cannot be transmitted between covered entities by e-mail.
False
True or False? Patients are entitled to a list of everyone with whom their health-
care provider has shared PHI.
True
True or False? PHI may be disclosed to someone involved in the patient's health
care without written authorization.
True
True or False? The Privacy Rule allows certain minors access to specified health
care, such as mental health counseling, without parental consent.
False
True or False? A Notice of Privacy Practice explains how patients' PHI is used and
disclosed.
True
True or False? An employee cannot be terminated for violating the Privacy Rule.
False
True or False? An individual may not sue his or her insurance company over a
HIPAA violation.
ASSESSMENT EXAM 1 2026/2027
WITH OVER 200 QUESTIONS AND
CORRECT ANSWERS RATED A+
Describe how to make a correction in a paper medical record.
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?
Acceptable
Is it acceptable or unacceptable according to generally accepted documentation
guidelines to make a late entry in a chart or medical record?
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?
Unacceptable
Is it acceptable or unacceptable according to generally accepted documentation
guidelines to make an entry in a record before seeing a patient?
Acceptable
Is it acceptable or unacceptable according to generally accepted documentation
guidelines to alter an entry in a medical record?
Unacceptable
,Is it acceptable or unacceptable according to generally accepted documentation
guidelines to stamp a record "signed but not read"?
Unacceptable
List five general principles of documentation that are based on CMS guidelines.
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.
a. Attorneys
b. Malpractice carriers
c. Jurors/Judges
d. Patients
e. CMS/JCAHO
True or False? CPT codes reflect the level of evaluation and management services
provided.
False
True or False? The three key elements of determining the level of service are
history, review of systems, and physical examination.
,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.
True
True or False? ICD codes indicate the reason for patient services.
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.
False
True or False? The medical record must include documentation that supports the
assessment.
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.
False
True or False? An ICD code should be as broad and encompassing as possible.
False
True or False? There is no code for "rule out."
True
True or False? Federal HIPAA regulations pre-empt state laws.
True
True or False? The Privacy Rule applies only to covered entities that transmit
medical information electronically.
True
, True or False? Protected Health Information is data that could be used to identify
an individual.
True
True or False? Covered entities include doctors, clinics, dentists, nursing homes,
chiropractors, psychologists, pharmacies, and insurance companies.
True
True or False? A covered entity may disclose PHI without patient authorization for
purposes of treatment, payment, or its health-care operations.
True
True or False? PHI cannot be transmitted between covered entities by e-mail.
False
True or False? Patients are entitled to a list of everyone with whom their health-
care provider has shared PHI.
True
True or False? PHI may be disclosed to someone involved in the patient's health
care without written authorization.
True
True or False? The Privacy Rule allows certain minors access to specified health
care, such as mental health counseling, without parental consent.
False
True or False? A Notice of Privacy Practice explains how patients' PHI is used and
disclosed.
True
True or False? An employee cannot be terminated for violating the Privacy Rule.
False
True or False? An individual may not sue his or her insurance company over a
HIPAA violation.
