Management QUESTIONS & ANSWERS 2026
| A+ GRADED 100% VERIFIED
• Documentation issue . Answer: Absence of objective measurable
information.
• Agency citation . Answer: CMS is most likely to cite the facility for a
forgotten signature on an order.
• Advance Directive (DNR) . Answer: Best document to support a
patient's decision to refuse CPR.
• Consultation report . Answer: Contains detailed assessments from
specialists.
• Hybrid record . Answer: Primary classification for records that include
both paper and electronic formats.
• Patient safety concern . Answer: Incorrect drug administration is the
most immediate concern when documentation is missing from the MAR.
• History and Physical . Answer: Document that must include the
patient's chief complaint, past medical history, and review of systems.
• Documentation standards . Answer: First correct action for an incorrect
blood pressure entry is to draw a line through the error and initial/date it.
• Approved-abbreviation policy . Answer: Requirement likely violated if
confusing and inconsistent abbreviations are used in MAR entries.
• Patient/member web portal . Answer: Feature that supports patients
accessing their lab results.
, • SOAP notes . Answer: The Assessment portion contains the provider's
clinical judgment.
• Documentation requirement . Answer: Completeness and dating
requirements are violated when daily progress notes are missing
timestamps.
• Inpatient discharge summary . Answer: Must include final diagnoses
and outcome to meet documentation standards.
• Scanned faxes . Answer: Classified as secondary data once stored
electronically.
• EMR artifacts . Answer: Part of the electronic content management
system
• Unreviewable external documentation . Answer: Documentation that
cannot be reviewed for accuracy or compliance
• Late entry . Answer: An entry made after the event has occurred,
which must be clearly identified
• H&P . Answer: History and Physical, a document that records a
patient's medical history and physical examination findings
• MAR . Answer: Medication Administration Record, a document that
tracks medications administered to a patient
• MPI . Answer: Master Patient Index, a database that maintains patient
information to avoid duplicate records
• SOAP progress note . Answer: A documentation format that includes
Subjective, Objective, Assessment, and Plan components