NURS 522 ADVANCED HEALTH ASSESSMENT EXAM 1 |
QUESTIONS AND ANSWERS | 2026 UPDATE | WITH
COMPLETE SOLUTION
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
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
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.
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.
QUESTIONS AND ANSWERS | 2026 UPDATE | WITH
COMPLETE SOLUTION
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
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
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.
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.
