MN 552 Advanced Health Assessment Midterm Exam: Advanced Health Assessment
Midterm Review of Quiz Questions 2026 UPDATES
List five general principles of documentation that are based on CMS guidelines. - (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. - (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. - (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? - (ANSWER)Acceptable
,MN 552 Advanced Health Assessment Midterm Exam: Advanced Health Assessment
Midterm Review of Quiz Questions 2026 UPDATES
Is it acceptable or unacceptable according to generally accepted documentation guidelines to make a
late entry in a chart or medical record? - (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? - (ANSWER)Unacceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to make an
entry in a record before seeing a patient? - (ANSWER)Acceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to alter an
entry in a medical record? - (ANSWER)Unacceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to stamp a
record "signed but not read"? - (ANSWER)Unacceptable
True or False? CPT codes reflect the level of evaluation and management services provided. -
(ANSWER)False
True or False? The three key elements of determining the level of service are history, review of systems,
and physical examination. - (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. - (ANSWER)True
True or False? ICD codes indicate the reason for patient services. - (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. - (ANSWER)False
,MN 552 Advanced Health Assessment Midterm Exam: Advanced Health Assessment
Midterm Review of Quiz Questions 2026 UPDATES
True or False? The medical record must include documentation that supports the assessment. -
(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. -
(ANSWER)False
True or False? An ICD code should be as broad and encompassing as possible. - (ANSWER)False
True or False? There is no code for "rule out." - (ANSWER)True
True or False? The complexity of medical decision-making takes into account the number of treatment
options. - (ANSWER)True
ICD codes are used to identify what? - (ANSWER)Physical exam findings, Reason for office visit,
Complaints, Diagnosis, Symptoms, Conditions
List five functions that an EMR system should be able to perform. - (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. - (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.
, MN 552 Advanced Health Assessment Midterm Exam: Advanced Health Assessment
Midterm Review of Quiz Questions 2026 UPDATES
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. - (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. - (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. - (ANSWER)True
True or False? Provides health care for everyone. - (ANSWER)False
Midterm Review of Quiz Questions 2026 UPDATES
List five general principles of documentation that are based on CMS guidelines. - (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. - (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. - (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? - (ANSWER)Acceptable
,MN 552 Advanced Health Assessment Midterm Exam: Advanced Health Assessment
Midterm Review of Quiz Questions 2026 UPDATES
Is it acceptable or unacceptable according to generally accepted documentation guidelines to make a
late entry in a chart or medical record? - (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? - (ANSWER)Unacceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to make an
entry in a record before seeing a patient? - (ANSWER)Acceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to alter an
entry in a medical record? - (ANSWER)Unacceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to stamp a
record "signed but not read"? - (ANSWER)Unacceptable
True or False? CPT codes reflect the level of evaluation and management services provided. -
(ANSWER)False
True or False? The three key elements of determining the level of service are history, review of systems,
and physical examination. - (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. - (ANSWER)True
True or False? ICD codes indicate the reason for patient services. - (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. - (ANSWER)False
,MN 552 Advanced Health Assessment Midterm Exam: Advanced Health Assessment
Midterm Review of Quiz Questions 2026 UPDATES
True or False? The medical record must include documentation that supports the assessment. -
(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. -
(ANSWER)False
True or False? An ICD code should be as broad and encompassing as possible. - (ANSWER)False
True or False? There is no code for "rule out." - (ANSWER)True
True or False? The complexity of medical decision-making takes into account the number of treatment
options. - (ANSWER)True
ICD codes are used to identify what? - (ANSWER)Physical exam findings, Reason for office visit,
Complaints, Diagnosis, Symptoms, Conditions
List five functions that an EMR system should be able to perform. - (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. - (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.
, MN 552 Advanced Health Assessment Midterm Exam: Advanced Health Assessment
Midterm Review of Quiz Questions 2026 UPDATES
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. - (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. - (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. - (ANSWER)True
True or False? Provides health care for everyone. - (ANSWER)False
