IHMO: Chapter 4 - Multiple Choice Exam Study Guide
The key to substantiating procedure and diagnostic code selections for proper
reimbursement is - ANSWER supporting documentation in the electronic health record
An electronic medical report is a - ANSWER both a and c: permanent legal document,
part of the health
An advantage of electronic medical records is - ANSWER greater standardization in
clinical medical terminology
When each entry in the medical record is worded similar to the previous entries, this is
considered ____ documentation. - ANSWER cloned
Under the Medicare incentive program for implementation of EHR, eligible providers will
____ demonstrated MU. - ANSWER be penalized through payment adjustments starting
in 2015 if they have not
The chronologic recording of pertinent facts and observations about the patient's health
is known as - ANSWER both b and c: documentation, charting
Reasons for documentation are - ANSWER both a and b: defense of a professional
liability claim, insurance carriers require accurate documentation that supports
procedure and diagnostic codes
the SOAP in patient medical record charting may be defines as - ANSWER S-subjective,
O-objective, A-assessment, P-plan
When a patient fails to return for needed treatment, documentation should be made -
ANSWER all of the above: in the patient's medical record, in the appointment book, on
the financial record or ledger card
The key to substantiating procedure and diagnostic code selections for proper
reimbursement is - ANSWER supporting documentation in the electronic health record
An electronic medical report is a - ANSWER both a and c: permanent legal document,
part of the health
An advantage of electronic medical records is - ANSWER greater standardization in
clinical medical terminology
When each entry in the medical record is worded similar to the previous entries, this is
considered ____ documentation. - ANSWER cloned
Under the Medicare incentive program for implementation of EHR, eligible providers will
____ demonstrated MU. - ANSWER be penalized through payment adjustments starting
in 2015 if they have not
The chronologic recording of pertinent facts and observations about the patient's health
is known as - ANSWER both b and c: documentation, charting
Reasons for documentation are - ANSWER both a and b: defense of a professional
liability claim, insurance carriers require accurate documentation that supports
procedure and diagnostic codes
the SOAP in patient medical record charting may be defines as - ANSWER S-subjective,
O-objective, A-assessment, P-plan
When a patient fails to return for needed treatment, documentation should be made -
ANSWER all of the above: in the patient's medical record, in the appointment book, on
the financial record or ledger card
