NURS 522 ADVANCED HEALTH
ASSESSMENT EXAM PREP QUESTIONS
WITH CORRECT ANSWERS
List five general principles of documentation that are based on CMS guidelines. - 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. - a. Attorneys
b. Malpractice carriers
c. Jurors/Judges
d. Patients
e. CMS/JCAHO
Describe how to make a correction in a paper medical record. - 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? - Acceptable
Is it acceptable or unacceptable according to generally accepted documentation
guidelines to make a late entry in a chart or medical record? - 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? -
Unacceptable
Is it acceptable or unacceptable according to generally accepted documentation
guidelines to make an entry in a record before seeing a patient? - Acceptable
Is it acceptable or unacceptable according to generally accepted documentation
guidelines to alter an entry in a medical record? - Unacceptable
Is it acceptable or unacceptable according to generally accepted documentation
guidelines to stamp a record "signed but not read"? - Unacceptable
True or False? CPT codes reflect the level of evaluation and management services
provided. - False
True or False? The three key elements of determining the level of service are history,
review of systems, and physical examination. - 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. - True
True or False? ICD codes indicate the reason for patient services. - 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. - False
True or False? The medical record must include documentation that supports the
assessment. - 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. - False
True or False? An ICD code should be as broad and encompassing as possible. - False
True or False? There is no code for "rule out." - True
True or False? The complexity of medical decision-making takes into account the
number of treatment options. - True
ICD codes are used to identify what? - Physical exam findings, Reason for office visit,
Complaints, Diagnosis, Symptoms, Conditions
,List five functions that an EMR system should be able to perform. - 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. - 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. - 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. - 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. -
True
True or False? Provides health care for everyone. - False
, True or False? Limits exclusion of pre-existing medical conditions to 24 months. - False
True or False? Gives patients more access to their medical records. - True
True or False? Protects medical records from improper uses and disclosures. - True
True or False? Federal HIPAA regulations pre-empt state laws. - True
True or False? The Privacy Rule applies only to covered entities that transmit medical
information electronically. - True
True or False? Protected Health Information is data that could be used to identify an
individual. - True
True or False? Covered entities include doctors, clinics, dentists, nursing homes,
chiropractors, psychologists, pharmacies, and insurance companies. - True
True or False? A covered entity may disclose PHI without patient authorization for
purposes of treatment, payment, or its health-care operations. - True
True or False? PHI cannot be transmitted between covered entities by e-mail. - False
True or False? Patients are entitled to a list of everyone with whom their health-care
provider has shared PHI. - True
True or False? PHI may be disclosed to someone involved in the patient's health care
without written authorization. - True
True or False? The Privacy Rule allows certain minors access to specified health care,
such as mental health counseling, without parental consent. - False
True or False? A Notice of Privacy Practice explains how patients' PHI is used and
disclosed. - True
True or False? An employee cannot be terminated for violating the Privacy Rule. - False
True or False? An individual may not sue his or her insurance company over a HIPAA
violation. - False
True or False? Criminal penalties for HIPAA violations can result in fines and
imprisonment. - True
True or False? The confidentiality, integrity, and availability of PHI need to be protected
only when the PHI is transmitted, not when it is stored. - False
