CIC Exam Prep Chapter 4 –
Documentation Questions With Answers
Who can make entries in the medical record? - Answer - Physicians, nurse practitioners, nurses, and
other members of the healthcare team.
Uniform Hospital Discharge Data Set
The data elements required by UHDDS include: - Answer - Personal Patient identifier
date of birth
Sex
race
ethnicity
residence
hospital identification
admission date
type of admission
discharge date
the attending physician's identification
Operating physician identification
PRINCIPAL diagnosis
OTHER diagnoses
external cause of injury codes
birth weight of neonates
Procedures and dates
disposition of patient
expected payment source
total charges
, Regardless of setting, Or regulatory or accreditation requirements, the healthcare record must support
the ________ and subsequent treatment of the patient. - Answer - condition (diagnosis)
The documentation found in the healthcare record justifies the _______ and _______ the patient
receives, and therefore must be adequate. - Answer - treatment and services
MDS: The minimum data set is required by CMS for ______ ________. - Answer - nursing facilities
The __________ is a tool that can be used to implement standardized assessments and management of
care and is a mandated process for all residents in a Medicare or Medicaid Certified nursing facility. -
Answer - MDS
The process to identify trends and patterns in a database. It can be useful in many ways, including
detecting fraud and abuse and identifying effective treatments and efficiencies. - Answer - Data mining
The health record/documentation pertaining to patient care is the property of the _____________. -
Answer - hospital or healthcare provider (professional setting) responsible for creating the record
The information contained in the medical record belongs to the individual _________. - Answer -
patient
The _________ must maintain control of the record to insure accuracy and maintain the patient's
privacy. - Answer - facility
The Institute of Medicine defines the users of the health record as, - Answer - "those individuals who
enter, verify, correct, analyze, or obtain information from the record either directly or indirectly."
The main users of the health record are the Clinicians responsible for direct patient care. Clinicians
should only access medical records of _________. - Answer - their own patients
Documentation Questions With Answers
Who can make entries in the medical record? - Answer - Physicians, nurse practitioners, nurses, and
other members of the healthcare team.
Uniform Hospital Discharge Data Set
The data elements required by UHDDS include: - Answer - Personal Patient identifier
date of birth
Sex
race
ethnicity
residence
hospital identification
admission date
type of admission
discharge date
the attending physician's identification
Operating physician identification
PRINCIPAL diagnosis
OTHER diagnoses
external cause of injury codes
birth weight of neonates
Procedures and dates
disposition of patient
expected payment source
total charges
, Regardless of setting, Or regulatory or accreditation requirements, the healthcare record must support
the ________ and subsequent treatment of the patient. - Answer - condition (diagnosis)
The documentation found in the healthcare record justifies the _______ and _______ the patient
receives, and therefore must be adequate. - Answer - treatment and services
MDS: The minimum data set is required by CMS for ______ ________. - Answer - nursing facilities
The __________ is a tool that can be used to implement standardized assessments and management of
care and is a mandated process for all residents in a Medicare or Medicaid Certified nursing facility. -
Answer - MDS
The process to identify trends and patterns in a database. It can be useful in many ways, including
detecting fraud and abuse and identifying effective treatments and efficiencies. - Answer - Data mining
The health record/documentation pertaining to patient care is the property of the _____________. -
Answer - hospital or healthcare provider (professional setting) responsible for creating the record
The information contained in the medical record belongs to the individual _________. - Answer -
patient
The _________ must maintain control of the record to insure accuracy and maintain the patient's
privacy. - Answer - facility
The Institute of Medicine defines the users of the health record as, - Answer - "those individuals who
enter, verify, correct, analyze, or obtain information from the record either directly or indirectly."
The main users of the health record are the Clinicians responsible for direct patient care. Clinicians
should only access medical records of _________. - Answer - their own patients
