NURS 522 Advanced Health Assessment Exam 1 –
Questions With Verified Solutions
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Terms in this set (286)
,List five general principles of a. The medical record should be complete and
documentation that are based on CMS legible.
guidelines. 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 a. Attorneys
providers, list five different types or b. Malpractice carriers
groups of people who could read c. Jurors/Judges
medical records you create. d. Patients
e. CMS/JCAHO
Describe how to make a correction in When making a correction in a paper record, you
a paper medical record. 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 Acceptable
according to generally accepted
documentation guidelines to use either
of the 1995 or 1997 CMS guidelines?
Is it acceptable or unacceptable Acceptable
according to generally accepted
documentation guidelines to make a
late entry in a chart or medical record?
Is it acceptable or unacceptable Unacceptable
according to generally accepted
documentation guidelines to use
correction fluid or tape to obliterate
an entry in a record?
Is it acceptable or unacceptable Acceptable
according to generally accepted
documentation guidelines to make an
entry in a record before seeing a
patient?
Is it acceptable or unacceptable Unacceptable
according to generally accepted
documentation guidelines to alter an
entry in a medical record?
Is it acceptable or unacceptable Unacceptable
according to generally accepted
documentation guidelines to stamp a
record "signed but not read"?
True or False? CPT codes reflect the False
level of evaluation and management
services provided.
, True or False? The three key elements False
of determining the level of service are
history, review of systems, and physical
examination.
True or False? Time spent counseling True
the patient and the nature of the
presenting problem are two factors
that affect the 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 False
more than 155,000 codes, but it does
not have the capacity to accommodate
new diagnoses and procedures.
True or False? The medical record True
must include documentation that
supports the assessment.
True or False? Assignment of False
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.
True or False? An ICD code should be False
as broad and encompassing as
possible.
True or False? There is no code for True
"rule out."
Questions With Verified Solutions
Add to calendar
Play your way to mastery with fun games
Match Blocks Charms NEW
Terms in this set (286)
,List five general principles of a. The medical record should be complete and
documentation that are based on CMS legible.
guidelines. 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 a. Attorneys
providers, list five different types or b. Malpractice carriers
groups of people who could read c. Jurors/Judges
medical records you create. d. Patients
e. CMS/JCAHO
Describe how to make a correction in When making a correction in a paper record, you
a paper medical record. 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 Acceptable
according to generally accepted
documentation guidelines to use either
of the 1995 or 1997 CMS guidelines?
Is it acceptable or unacceptable Acceptable
according to generally accepted
documentation guidelines to make a
late entry in a chart or medical record?
Is it acceptable or unacceptable Unacceptable
according to generally accepted
documentation guidelines to use
correction fluid or tape to obliterate
an entry in a record?
Is it acceptable or unacceptable Acceptable
according to generally accepted
documentation guidelines to make an
entry in a record before seeing a
patient?
Is it acceptable or unacceptable Unacceptable
according to generally accepted
documentation guidelines to alter an
entry in a medical record?
Is it acceptable or unacceptable Unacceptable
according to generally accepted
documentation guidelines to stamp a
record "signed but not read"?
True or False? CPT codes reflect the False
level of evaluation and management
services provided.
, True or False? The three key elements False
of determining the level of service are
history, review of systems, and physical
examination.
True or False? Time spent counseling True
the patient and the nature of the
presenting problem are two factors
that affect the 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 False
more than 155,000 codes, but it does
not have the capacity to accommodate
new diagnoses and procedures.
True or False? The medical record True
must include documentation that
supports the assessment.
True or False? Assignment of False
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.
True or False? An ICD code should be False
as broad and encompassing as
possible.
True or False? There is no code for True
"rule out."
