NURS 522 ADVANCED HEALTH
ASSESSMENT EXAM 1
1. List five general principles of documentation that are based on CMS guide-
lines.
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 careJurors/Judges
• 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.
,2. 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. Patients
d. CMS/JCAHO
3. 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.
4. Is it acceptable or unacceptable according to generally accepted documenta-
tion guidelines to use either of the 1995 or 1997 CMS guidelines?
,Answer Acceptable
5. Is it acceptable or unacceptable according to generally accepted documenta-
tion guidelines to make a late entry in a chart or medical record?
Answer Acceptable
6. Is it acceptable or unacceptable according to generally accepted documen-
tation guidelines to use correction fluid or tape to obliterate an entry in a
record?
Answer Unacceptable
7. Is it acceptable or unacceptable according to generally accepted documenta-
tion guidelines to make an entry in a record before seeing a patient?
Answer Acceptable
8. Is it acceptable or unacceptable according to generally accepted documenta-
tion guidelines to alter an entry in a medical record?
Answer Unacceptable
, 9. Is it acceptable or unacceptable according to generally accepted documenta-
tion guidelines to stamp a record "signed but not read"?
Answer Unacceptable
10. True or False? CPT codes reflect the level of evaluation and management
services provided.
Answer False
11. True or False? The three key elements of determining the level of service are
history, review of systems, and physical examination.
Answer False
12. 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
13. True or False? ICD codes indicate the reason for patient services.
Answer True
ASSESSMENT EXAM 1
1. List five general principles of documentation that are based on CMS guide-
lines.
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 careJurors/Judges
• 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.
,2. 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. Patients
d. CMS/JCAHO
3. 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.
4. Is it acceptable or unacceptable according to generally accepted documenta-
tion guidelines to use either of the 1995 or 1997 CMS guidelines?
,Answer Acceptable
5. Is it acceptable or unacceptable according to generally accepted documenta-
tion guidelines to make a late entry in a chart or medical record?
Answer Acceptable
6. Is it acceptable or unacceptable according to generally accepted documen-
tation guidelines to use correction fluid or tape to obliterate an entry in a
record?
Answer Unacceptable
7. Is it acceptable or unacceptable according to generally accepted documenta-
tion guidelines to make an entry in a record before seeing a patient?
Answer Acceptable
8. Is it acceptable or unacceptable according to generally accepted documenta-
tion guidelines to alter an entry in a medical record?
Answer Unacceptable
, 9. Is it acceptable or unacceptable according to generally accepted documenta-
tion guidelines to stamp a record "signed but not read"?
Answer Unacceptable
10. True or False? CPT codes reflect the level of evaluation and management
services provided.
Answer False
11. True or False? The three key elements of determining the level of service are
history, review of systems, and physical examination.
Answer False
12. 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
13. True or False? ICD codes indicate the reason for patient services.
Answer True
