CIC Exam Prep Chapter 4 – Documentation Questions and Answers
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Course
CIC
Institution
CIC
CIC Exam Prep Chapter 4 –
Documentation Questions and Answers
Who can make entries in the medical record? - Answer-Physicians, nurse practitioners, nurses, and
other members of the healthcare team.
Uniform Hospital Discharge Data Set
The data elements required by UHDDS include: - Answer-Pers...
Regardless of setting, Or regulatory or accreditation requirements, the healthcare record must support
the ________ and subsequent treatment of the patient. - Answer✔✔-condition (diagnosis)
The documentation found in the healthcare record justifies the _______ and _______ the patient
receives, and therefore must be adequate. - Answer✔✔-treatment and services
MDS: The minimum data set is required by CMS for ______ ________. - Answer✔✔-nursing facilities
The __________ is a tool that can be used to implement standardized assessments and management of
care and is a mandated process for all residents in a Medicare or Medicaid Certified nursing facility. -
Answer✔✔-MDS
The process to identify trends and patterns in a database. It can be useful in many ways, including
detecting fraud and abuse and identifying effective treatments and efficiencies. - Answer✔✔-Data
mining
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