Test Bank for Guide to Clinical Documentation,
3rd Edition by Debra D. Sullivan | Chapters 1–12 |
Practice Questions & Answers With rationales |
Comprehensive Study Guide
,
,Chapter 1: Medicolegal Principles of Documentation
Multiple Choice Questions
1. According to CMS guidelines, which of the following is NOT one of
the general principles of documentation?
• A) The medical record should be complete and legible
• B) Past and present diagnoses should be accessible to treating and
consulting providers
• C) The medical record should include personal opinions about the
patient's character
• D) Appropriate health risk factors should be identified
Answer: C
Rationale: The CMS guidelines emphasize objective documentation.
Personal, subjective opinions regarding the patient, the patient's family, or
other providers do not belong in the medical record. Documentation
should focus on facts, not opinions.
2. Which of the following best describes the purpose of the Health
Insurance Portability and Accountability Act (HIPAA) Privacy Rule?
• A) To ensure all patients have health insurance coverage
• B) To protect the confidentiality of individually identifiable health
information
• C) To establish standards for electronic prescribing
• D) To regulate the cost of healthcare services
Answer: B
Rationale: The Privacy Rule was written to protect the confidentiality of
individually identifiable health information. It limits the use and disclosure
of certain individually identifiable health information and gives patients the
right to access their medical records.
, 3. When correcting an error in a paper medical record, the healthcare
provider should:
• A) Use correction fluid to cover the error
• B) Draw a single line through the erroneous text, initial and date the
entry, and label it as an error
• C) Completely remove the page and rewrite it
• D) Write over the erroneous text to make it illegible
Answer: B
Rationale: 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. You should never obliterate an original note, nor should
you use correction fluid or tape.
4. The downcoding process occurs when:
• A) A patient receives a lower level of care than needed
• B) An insurance company reduces the value of a procedure and resulting
reimbursement
• C) A provider documents an incorrect diagnosis
• D) A patient is denied coverage for a procedure
Answer: B
Rationale: Downcoding is the process by which an insurance company
reduces the value of a procedure or encounter and resulting
reimbursement because either (1) there is a mismatch of CPT code and
description, or (2) the ICD code does not justify the procedure or level of
service.
5. What is the primary purpose of the HITECH Act?
• A) To provide health insurance for children
• B) To offer financial incentives for healthcare providers who comply with
"meaningful use" standards for EMR technology
• C) To regulate pharmaceutical companies
3rd Edition by Debra D. Sullivan | Chapters 1–12 |
Practice Questions & Answers With rationales |
Comprehensive Study Guide
,
,Chapter 1: Medicolegal Principles of Documentation
Multiple Choice Questions
1. According to CMS guidelines, which of the following is NOT one of
the general principles of documentation?
• A) The medical record should be complete and legible
• B) Past and present diagnoses should be accessible to treating and
consulting providers
• C) The medical record should include personal opinions about the
patient's character
• D) Appropriate health risk factors should be identified
Answer: C
Rationale: The CMS guidelines emphasize objective documentation.
Personal, subjective opinions regarding the patient, the patient's family, or
other providers do not belong in the medical record. Documentation
should focus on facts, not opinions.
2. Which of the following best describes the purpose of the Health
Insurance Portability and Accountability Act (HIPAA) Privacy Rule?
• A) To ensure all patients have health insurance coverage
• B) To protect the confidentiality of individually identifiable health
information
• C) To establish standards for electronic prescribing
• D) To regulate the cost of healthcare services
Answer: B
Rationale: The Privacy Rule was written to protect the confidentiality of
individually identifiable health information. It limits the use and disclosure
of certain individually identifiable health information and gives patients the
right to access their medical records.
, 3. When correcting an error in a paper medical record, the healthcare
provider should:
• A) Use correction fluid to cover the error
• B) Draw a single line through the erroneous text, initial and date the
entry, and label it as an error
• C) Completely remove the page and rewrite it
• D) Write over the erroneous text to make it illegible
Answer: B
Rationale: 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. You should never obliterate an original note, nor should
you use correction fluid or tape.
4. The downcoding process occurs when:
• A) A patient receives a lower level of care than needed
• B) An insurance company reduces the value of a procedure and resulting
reimbursement
• C) A provider documents an incorrect diagnosis
• D) A patient is denied coverage for a procedure
Answer: B
Rationale: Downcoding is the process by which an insurance company
reduces the value of a procedure or encounter and resulting
reimbursement because either (1) there is a mismatch of CPT code and
description, or (2) the ICD code does not justify the procedure or level of
service.
5. What is the primary purpose of the HITECH Act?
• A) To provide health insurance for children
• B) To offer financial incentives for healthcare providers who comply with
"meaningful use" standards for EMR technology
• C) To regulate pharmaceutical companies
