NURS 522 ADVANCED HEALTH ASSESSMENT EXAM 1 QUESTIONS AND
ANSWERS
List five general principles of documentation that are based on CMS guidelines. - CORRECT
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. - CORRECT 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. - CORRECT 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? - CORRECT ANSWER✅✅Acceptable
,Is it acceptable or unacceptable according to generally accepted documentation guidelines to make a
late entry in a chart or medical record? - CORRECT 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? - CORRECT ANSWER✅✅Unacceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to make an
entry in a record before seeing a patient? - CORRECT ANSWER✅✅Acceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to alter an
entry in a medical record? - CORRECT ANSWER✅✅Unacceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to stamp a
record "signed but not read"? - CORRECT ANSWER✅✅Unacceptable
True or False? CPT codes reflect the level of evaluation and management services provided. - CORRECT
ANSWER✅✅False
True or False? The three key elements of determining the level of service are history, review of systems,
and physical examination. - CORRECT 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. - CORRECT ANSWER✅✅True
True or False? ICD codes indicate the reason for patient services. - CORRECT 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. - CORRECT ANSWER✅✅False
True or False? The medical record must include documentation that supports the assessment. -
CORRECT 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. -
CORRECT ANSWER✅✅False
True or False? An ICD code should be as broad and encompassing as possible. - CORRECT
ANSWER✅✅False
True or False? There is no code for "rule out." - CORRECT ANSWER✅✅True
True or False? The complexity of medical decision-making takes into account the number of treatment
options. - CORRECT ANSWER✅✅True
ICD codes are used to identify what? - CORRECT ANSWER✅✅Physical exam findings, Reason for office
visit, Complaints, Diagnosis, Symptoms, Conditions
List five functions that an EMR system should be able to perform. - CORRECT 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. - CORRECT 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.
e) Patients would be provided tools that give them access to their health records and interactive patient
education and that would help them carry out home-monitoring and self-testing to improve control of
chronic conditions.
Identify at least five potential barriers to implementing an EMR system. - CORRECT ANSWER✅✅Limited
computer literacy on the part of providers
b) Concerns over security, productivity, patient satisfaction, and unreliable technology
c) Costs of hardware and software
d) Concerns about safety and security of systems and the ability to protect and keep private confidential
health information
e) Technical matters, such as functionality, ease of use, and customer support from vendors are other
barriers
List at least two criteria required to meet "meaningful use" standards. - CORRECT
ANSWER✅✅Providers have to show that they are meeting certain measurement thresholds that range
from recording patient information as structured data to exchanging summary care records.
b) The HITECH Act imposes requirements for notification of a data breach related to unauthorized uses
and disclosures of "unsecured protected health information" (PHI).
True or False? HIPAA establishes standards for the electronic transfer of health data. - CORRECT
ANSWER✅✅True
True or False? Provides health care for everyone. - CORRECT ANSWER✅✅False
True or False? Limits exclusion of pre-existing medical conditions to 24 months. - CORRECT
ANSWER✅✅False
True or False? Gives patients more access to their medical records. - CORRECT ANSWER✅✅True
ANSWERS
List five general principles of documentation that are based on CMS guidelines. - CORRECT
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. - CORRECT 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. - CORRECT 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? - CORRECT ANSWER✅✅Acceptable
,Is it acceptable or unacceptable according to generally accepted documentation guidelines to make a
late entry in a chart or medical record? - CORRECT 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? - CORRECT ANSWER✅✅Unacceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to make an
entry in a record before seeing a patient? - CORRECT ANSWER✅✅Acceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to alter an
entry in a medical record? - CORRECT ANSWER✅✅Unacceptable
Is it acceptable or unacceptable according to generally accepted documentation guidelines to stamp a
record "signed but not read"? - CORRECT ANSWER✅✅Unacceptable
True or False? CPT codes reflect the level of evaluation and management services provided. - CORRECT
ANSWER✅✅False
True or False? The three key elements of determining the level of service are history, review of systems,
and physical examination. - CORRECT 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. - CORRECT ANSWER✅✅True
True or False? ICD codes indicate the reason for patient services. - CORRECT 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. - CORRECT ANSWER✅✅False
True or False? The medical record must include documentation that supports the assessment. -
CORRECT 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. -
CORRECT ANSWER✅✅False
True or False? An ICD code should be as broad and encompassing as possible. - CORRECT
ANSWER✅✅False
True or False? There is no code for "rule out." - CORRECT ANSWER✅✅True
True or False? The complexity of medical decision-making takes into account the number of treatment
options. - CORRECT ANSWER✅✅True
ICD codes are used to identify what? - CORRECT ANSWER✅✅Physical exam findings, Reason for office
visit, Complaints, Diagnosis, Symptoms, Conditions
List five functions that an EMR system should be able to perform. - CORRECT 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. - CORRECT 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.
e) Patients would be provided tools that give them access to their health records and interactive patient
education and that would help them carry out home-monitoring and self-testing to improve control of
chronic conditions.
Identify at least five potential barriers to implementing an EMR system. - CORRECT ANSWER✅✅Limited
computer literacy on the part of providers
b) Concerns over security, productivity, patient satisfaction, and unreliable technology
c) Costs of hardware and software
d) Concerns about safety and security of systems and the ability to protect and keep private confidential
health information
e) Technical matters, such as functionality, ease of use, and customer support from vendors are other
barriers
List at least two criteria required to meet "meaningful use" standards. - CORRECT
ANSWER✅✅Providers have to show that they are meeting certain measurement thresholds that range
from recording patient information as structured data to exchanging summary care records.
b) The HITECH Act imposes requirements for notification of a data breach related to unauthorized uses
and disclosures of "unsecured protected health information" (PHI).
True or False? HIPAA establishes standards for the electronic transfer of health data. - CORRECT
ANSWER✅✅True
True or False? Provides health care for everyone. - CORRECT ANSWER✅✅False
True or False? Limits exclusion of pre-existing medical conditions to 24 months. - CORRECT
ANSWER✅✅False
True or False? Gives patients more access to their medical records. - CORRECT ANSWER✅✅True
