Deck 4: Medical Documentation and the Electronic Health Record

Question 1

When a discussion takes place with a patient concerning the risks and benefits of treatment options, it is considered

A) an office visit.
B) a consultation.
C) counseling.
D) a "no-charge" visit.

Answer 1

counseling.

Question 2

Under the Medicare incentive program for implementation of EHR, eligible providers will

A) earn incentive payments for up to 4 years if they have demonstrated MU.
B) earn incentive payments for up to 10 years if they have demonstrated MU.
C) be penalized through payment adjustments starting in 2013 if they have not demonstrated MU.
D) be penalized through payment adjustments starting in 2015 if they have not demonstrated MU.

Answer 2

be penalized through payment adjustments starting in 2015 if they have not demonstrated MU.

Question 3

When a patient fails to return for needed treatment, documentation should be made

A) in the patient's medical record.
B) in the appointment book.
C) on the financial record or ledger card.
D) all of the above.

Answer 3

all of the above.

Question 4

A new patient is one who

A) has not received any professional services from another physician of the same specialty within the past 4 years.
B) has not received any professional services from a physician who belongs to a group practice within the past 2 years.
C) has not received any professional services from the physician within the past 3 years.
D) has not received any professional services from the physician within the past 5 years.

Question 5

The key to substantiating procedure and diagnostic code selections for proper reimbursement is

A) the information on the daysheet.
B) supporting documentation in the electronic health record.
C) the data on the patient's information sheet.
D) the data checked off on the patient's encounter form.

Question 6

An electronic medical report is a

A) permanent legal document.
B) progress note.
C) part of the health record.
D) both a and c

Question 7

The chronologic recording of pertinent facts and observations about the patient's health is known as

A) evidence.
B) documentation.
C) charting.
D) both b and c

Question 8

In dealing with managed care plans, a referral is

A) the same as a consultation.
B) the transfer of the total or specific care of a patient from one physician to another.
C) the term used when requesting an authorization for the patient to receive services elsewhere.
D) both b and c

Question 9

A diseased condition or state is known as

A) pathology.
B) morbidity.
C) mortality.
D) complication.

Question 10

An established patient is one who

A) has received professional services from a physician who belongs to a group practice within the past 2 years.
B) has previously received professional services from a physician or another physician of the same specialty who belongs to the group practice within the past 3 years.
C) has received professional services from another physician of the same specialty within the past 4 years.
D) has received professional services from a physician within the past 5 years.

Question 11

When each entry in the medical record is worded similar to the previous entries, this is considered

A) correct documentation.
B) current documentation.
C) cloned documentation.
D) legal documentation.

Question 12

A concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for the encounter is abbreviated as

A) CC.
B) HPI.
C) ROS.
D) PFSH.

Question 13

What does comorbidity mean?

A) The act of identifying a disease from its signs and symptoms
B) A forecast of the course of a disease
C) Underlying diseases or other conditions present at the time of the visit
D) Continuity of care

Question 14

Your physician has been to the hospital providing constant bedside attention and treating a patient in respiratory failure. These services are considered

A) hospital consultation.
B) critical care.
C) emergency care.
D) hospital observation.

Question 15

Reasons for documentation include

A) defense of a professional liability claim.
B) insurance carriers require accurate documentation that supports procedure and diagnostic codes.
C) both a and b
D) none of the above.

Question 16

Levels of evaluation and management services are based on type(s) of physical examination that may be

A) limited.
B) complete.
C) problem focused.
D) both a and b

Question 17

How should an entry in a patient's electronic medical record be corrected?

A) Input a note of which section is in error and enter correct data with details of why the correction is necessary and authenticate with electronic signature, date, and time.
B) Key over the incorrect entry, substitute the correct information, date, and electronically initial the entry.
C) Delete the incorrect entry, substitute the correct information, date, and electronically initial the entry.
D) Substitute the correct information by inserting an amendment keyed over the incorrect information.

Question 18

An expanded problem-focused examination is a/an

A) expanded examination of a single organ system.
B) extended examination of the affected body area.
C) limited examination of the affected body area.
D) general examination of a single organ system.

Question 19

An advantage of electronic medical records is

A) increased confidentiality and security.
B) ease in learning and using the technology.
C) low start-up costs.
D) greater standardization in clinical medical terminology.

Question 20

The SOAP in patient medical record charting may be defined as

A) S-symptoms, O-observations, A-actual findings, P-procedures.
B) S-subjective, O-objective, A-assessment, P-plan.
C) S-signs, O-observations, A-auscultation, P-percussion.
D) S-standardized, O-original, A-assessment, P-plan.

Question 21

Most insurance companies perform routine ____________________ on practices with unusual billing patterns or excessive payment amounts.

Question 22

The official American Hospital Association policy states that "abbreviations should be totally eliminated from the more vital sections of the record, such as the"

A) final diagnosis.
B) operative notes.
C) discharge summaries.
D) all of the above.

Question 23

Criteria used by insurance companies when making decisions to limit or deny payment in which medical services or procedures must be justified by the patient's symptoms and diagnosis are called ____________________.

Question 24

The section of Current Procedural Terminology (CPT) codes which are used to report office and other types of visits with health care professionals is referred to as _________________.

Question 25

The code for repair of a superficial laceration is found in the CPT Integumentary/Surgery section under the heading

A) Simple.
B) Intermediate.
C) Complex.
D) Decontamination and/or Débridement.

Question 26

Incentive programs for adoption of EHR will transition into ______________ for those who do not adopt HER over the next several years in the form of adjustments.

Question 27

Preservation of health records is governed by

A) federal law.
B) state law.
C) local law.
D) both b and c

Question 28

Who may accept a subpoena?

A) The prospective witness
B) An authorized person
C) Both a and b
D) Neither a nor b

Question 29

It is the responsibility of the ____________________ to handwrite or dictate the documentation for medical transcription.

Question 30

Parts of the small and large intestines, right ovary, right uterine tube, appendix, and right ureter are found in the

A) right upper quadrant.
B) epigastric region.
C) right lower quadrant.
D) hypogastric region.

Question 31

Under the Federal False Claims Act, records that should be retained indefinitely include

A) payroll records and invoice and billing records.
B) appointment sheets and postal and meter records.
C) x-ray films, laboratory reports, and pathologic specimens.
D) accounts receivable ledgers, deceased patients' medical records, and petty cash vouchers.

Question 32

____________________ is a term used to define those providers or hospitals that have the capabilities and processes in place to actively use certified electronic health record technology.

Question 33

Medications which are prescribed and being taken by the patient should be listed in the health record, specifying frequency and ______________.

Question 34

Once an individual has been found guilty of committing a Medicare or Medicaid program-related crime,

A) exclusion from program participation is mandatory.
B) exclusion from program participation will be decided.
C) the individual will be monitored at frequent intervals in the future.
D) none of the above.

Question 35

If a professional liability claim is filed by a patient, good ____________________ helps establish a strong defense.

Question 36

A review of patient records done before billing is submitted is called

A) internal.
B) prospective.
C) internal audit.
D) retrospective.

Question 37

Repair of lacerations that require layered closure of one or more of the deeper layers of the skin and tissues is known as

A) simple.
B) complex.
C) intermediate.
D) cosmetic.

Question 38

Written information documenting facts and events that were rendered as patient care is referred to as a _____________________.

Question 39

A statement describing symptoms and problems as a reason for the office visit is known as the patient's ____________________.

Question 40

A reference list of all staff members' names, job titles, signatures, and initials is known as a/an ____________________.

Question 41

WNL is the abbreviation for _________________________.

Question 42

When a patient receives similar services by more than one physician on the same day, it is called ____________________ care.

Question 43

When documenting a case for billing, a level must be determined from one of ____________________ types of medical decision making.

Question 44

The abbreviation HPI stands for ______________________________.

Question 45

An internal review known as a ______________________________ is done after billing insurance carriers.

Question 46

The term ____________________ refers to a disease that persists over a long time.

Question 47

As a health insurance claims professional, you may be required to _______ information from a medical record to justify a Health Insurance Claim Form after professional services are rendered.

Question 48

PFSH is the abbreviation for ___________________________________.

Question 49

A disease that runs a short but relatively severe course is referred to as ____________________.

Question 50

The upper middle region above the stomach is known as the ____________________ region.

Question 51

Identify three ways that a physician may withdraw formally from further provision of care to a patient when the patient is noncompliant.

Question 52

Review of medical events in the patient's family, including diseases that may be hereditary, is known as a/an ____________________.

Question 53

If you are in doubt about the documentation in any health record, to obtain the most specific and accurate terminology, you should ______________ the physician.

Question 54

For a complete ROS, at least _____ organ systems must be reviewed and documented.

Question 55

An age-appropriate review of past and current activities of the patient (e.g., smoking or use of alcohol) is known as a/an ____________________.

Question 56

The documentation of the patient's previous experiences with illnesses, operations, injuries, and treatments is known as the ____________________.

Question 57

An inventory of body systems obtained through a series of questions that are used to identify signs and/or symptoms of the patient is known as a/an ____________________.

Question 58

The four levels of physical examination are referred to as problem focused, expanded problem focused, ____________, and comprehensive.

Question 59

Explain the methods for disposing of both paper and electronic records.

Question 60

At least _______ elements of the HPI or the status of at least three chronic conditions is required for the extended level of HPI.

Question 61

Match each of these types of medical services to the correct definition.

Intensive care provided during an acute life-threatening condition that requires constant bedside attention by the physician.

A)Concurrent care
B)Consultation
C)Continuity of care
D)Counseling
E)Critical care
F)Emergency
G)Referral

Question 62

Match each of these terms, as they are used in a medical office, with the correct definition.

Situation associated with the pain/symptom.

A)Location
B)Quality
C)Severity
D)Duration
E)Timing
F)Context
G)Modifying factors
H)Associated signs and symptoms

Question 63

Match each of these types of medical services to the correct definition.

Providing similar services to the same patient by more than one physician on the same day.

A)Concurrent care
B)Consultation
C)Continuity of care
D)Counseling
E)Critical care
F)Emergency
G)Referral

Question 64

Match each of these terms, as they are used in a medical office, with the correct definition.

Things done to make the symptom/pain worse or better.

A)Location
B)Quality
C)Severity
D)Duration
E)Timing
F)Context
G)Modifying factors
H)Associated signs and symptoms

Question 65

Match each of these types of medical services to the correct definition.

Transfer of the total care of a patient from one physician to another.

A)Concurrent care
B)Consultation
C)Continuity of care
D)Counseling
E)Critical care
F)Emergency
G)Referral

Question 66

Match each of these types of medical services to the correct definition.

Care provided during a life-threatening condition in the hospital emergency department.

A)Concurrent care
B)Consultation
C)Continuity of care
D)Counseling
E)Critical care
F)Emergency
G)Referral

Question 67

Match each of these terms, as they are used in a medical office, with the correct definition.

How long the symptom/pain has been present and how long it lasts when the patient has it.

A)Location
B)Quality
C)Severity
D)Duration
E)Timing
F)Context
G)Modifying factors
H)Associated signs and symptoms

Question 68

Match each of these terms, as they are used in a medical office, with the correct definition.

When the pain/symptom occurs

A)Location
B)Quality
C)Severity
D)Duration
E)Timing
F)Context
G)Modifying factors
H)Associated signs and symptoms.

Question 69

Match these types of physicians with the description of the services each provides.

Provider who sends the patient for tests or treatment.

A)Attending physician
B)Consulting physician
C)Ordering physician
D)Referring physician
E)Treating or performing physician

Question 70

Match each of these terms, as they are used in a medical office, with the correct definition.

Area of the body in which the symptom is occurring.

A)Location
B)Quality
C)Severity
D)Duration
E)Timing
F)Context
G)Modifying factors
H)Associated signs and symptoms

Question 71

Match these types of physicians with the description of the services each provides.

Individual who directs the selection, preparation, or administration of tests, medications, or treatment.

A)Attending physician
B)Consulting physician
C)Ordering physician
D)Referring physician
E)Treating or performing physician

Question 72

Match each of these terms, as they are used in a medical office, with the correct definition.

Symptom/pain and other changes that are noted when the symptom/pain occurs.

A)Location
B)Quality
C)Severity
D)Duration
E)Timing
F)Context
G)Modifying factors
H)Associated signs and symptoms

Question 73

Match these types of physicians with the description of the services each provides.

Provider whose opinion is requested by another physician about evaluation and management of a specific problem.

A)Attending physician
B)Consulting physician
C)Ordering physician
D)Referring physician
E)Treating or performing physician

Question 74

Match each of these types of medical services to the correct definition.

Providing treatment for a patient and subsequent referral by the treating physician to another physician for treatment of the same condition.

A)Concurrent care
B)Consultation
C)Continuity of care
D)Counseling
E)Critical care
F)Emergency
G)Referral

Question 75

Match each of these types of medical services to the correct definition.

Services rendered by a physician whose opinion is requested by another physician for evaluating a patient's illness.

A)Concurrent care
B)Consultation
C)Continuity of care
D)Counseling
E)Critical care
F)Emergency
G)Referral

Question 76

Match these types of physicians with the description of the services each provides.

Provider who is the medical staff member legally responsible for the care and treatment given to a patient.

A)Attending physician
B)Consulting physician
C)Ordering physician
D)Referring physician
E)Treating or performing physician

Question 77

Match each of these terms, as they are used in a medical office, with the correct definition.

Degree of symptom and/or pain on a scale from 1 to 10.

A)Location
B)Quality
C)Severity
D)Duration
E)Timing
F)Context
G)Modifying factors
H)Associated signs and symptoms

Question 78

Match these types of physicians with the description of the services each provides.

Provider who renders a service to a patient.

A)Attending physician
B)Consulting physician
C)Ordering physician
D)Referring physician
E)Treating or performing physician

Question 79

Match each of these types of medical services to the correct definition.

Discussion with a patient, family, or both about diagnostic results and instructions for treatment.

A)Concurrent care
B)Consultation
C)Continuity of care
D)Counseling
E)Critical care
F)Emergency
G)Referral

Question 80

Match each of these terms, as they are used in a medical office, with the correct definition.

Character of the symptom/pain (burning, gnawing).

A)Location
B)Quality
C)Severity
D)Duration
E)Timing
F)Context
G)Modifying factors
H)Associated signs and symptoms