s3.amazonaws.com · Web viewin the emergency room all of the above Part IV True/False Questions F A patient’s hospital discharge summary contains the discharge diagnosis but not

4Workbook Answer Key forMedical Documentation and the Electronic Health Record

ANSWERSAssignment 4-1 Review QuestionsPart I Fill-in-the-Blank

1. Written or graphic information about patient care is termed a/an health record.2. List three of the various types of health record systems that can be used in a medical practice.

1) Problem-oriented record system2) Source-oriented record system 3) Integrated record system.

3. The difference between an EMR and an EHR is that the EMR is an individual physician’s record of the patient’s care, whereas the EHR is all of the patient’s records, from many different information systems and providers.

4. The greatest advantage of an EHR system is the improvement of quality of care and patient safety through the accessibility of medical records between providers and other health care organizations.

5. Providers who are not participating in the E-Prescribing Incentive Program in 2014 will have Medicare claims processed with a 2.0 percent adjustment/reduction in their payments.

6. Stage 2 of the Meaningful Use Incentive Program will focus on advance clinical processes which will expand their criteria in areas of disease management, clinical decision support, medication management, transitions in care, quality measurement, and research.

7. What is CMS’s definition of legible documentation? That which is recognizable by someone outside of the medical practice who is unfamiliar with the handwriting.

8. Performance of services or procedures consistent with the diagnosis, done with standards of good medical practice and a proper level of care given in the appropriate setting, is known as medical necessity.

9. Medicare administrative contractors have walk-in rights to access a medical practice without an appointment or search warrant to conduct a review of documentation, audits, and evaluations.

10. A list of all staff members’ names, job titles, signatures, and their initials is known as a/an signature log.11. For electronic health records, how should an insurance billing specialist correct an error on a patient’s

record? Note that if a section is in error with the date and time, then enter the correct information with a notation of when and why the physician changed the entry. Authenticate the correction via electronic signature and date.

12. For paper-based records, how should an error be corrected on a patient’s record? Use legal copy pen, cross out wrong entry with a single line, write the correct entry, date, and initial entry. Never erase or use white-out or self-adhesive paper over an error.

13. If a medical practice is audited by Medicare officials and intentional miscoding is discovered, fines and penalties may be levied and providers may be excluded from the program.

14. Name the six documentation components of a patient`s history:a. chief complaintb. history of present illnessc. review of systemsd. past historye. family historyf. social history

Insurance Handbook for the Medical Office, 13th ed.Copyright © 2014 by Saunders, an imprint of Elsevier Inc. All rights reserved. Fordney

23 Chapter 4 Medical Documentation and The Electronic Health Record ____________________________

15. List the eight descriptive elements that can be documented in the HPI: 1. Location, 2. Quality, 3. Severity, 4. Duration, 5. Timing, 6. Context, 7. Modifying Factors, and 8. Associated Signs and Symptoms

16. List the body systems that are recognized for reporting of the ROS. Constitutional, eyes, ears, nose, mouth, throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurologic, psychiatric, endocrine, hematologic/lymphatic, and allergic/immunologic.

17. A problem-focused examination is a limited examination of the affected body area or organ system. 18. MDM is the process performed after taking the patient’s history and performing the examination

which results in a plan of treatment.19. Define the following terms in relationship to billing:

a. New patient: one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past 3 years.

b. Established patient: one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past 3 years.

20. Explain the difference between a consultation and the referral of a patient:a. Consultation: Services rendered by a physician whose opinion or advice is requested by

another physician or agency in the evaluation or treatment of a patient’s illness or a suspected problem.

b. Referral: Transfer of the total or specific care of a patient from one physician to another for known problems.

21. Medical care for a patient who has received treatment for an illness and is referred to a second physician for treatment of the same condition is a situation called continuity of care.

22. An emergency medical condition, as defined by Medicare, is a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the patient’s health in serious jeopardy, serious impairment to body functions, or serious dysfunction of any body organ or part.

23. Whenever the words “rule out” are used to describe a patient’s condition, do not code these conditions as if they existed; instead code the sign or symptom.

24. Any charts which are amended with additional notes must be labeled “Addendum” or “late entry” and dated on the day of the amendment, and signed by the physician.

25. If a fax is misdirected, either telephone or complete a misdirected fax form online and fax it to the original phone number.

Part II Mix and Match Questions26. Match the following terms in the right column with their descriptions and fill in the blank with the

appropriate letter. i Renders a service to a patient a. Attending physiciand Directs selection, preparation, and administration b. Consulting physician of tests, medication, or treatment c. Non-physician practitionera Legally responsible for the care and treatment d. Ordering physician

given to a patient e. Primary care physicianb Gives an opinion regarding a specific problem f. Referring physician

that is requested by another doctor g. Resident physicianf Sends the patient for tests or treatment or to another h. Teaching physician

physician for consultation i. Treating or performing physician


______________________________ Chapter 4 Medical Documentation and the Electronic Health Record 24

e Oversees care of patients in managed care plans and refers patients to see specialists when needed

h Responsible for training and supervising medical students c Clinical nurse specialist or licensed social worker who treats

a patient for a specific medical problem and uses the resultsof a diagnostic test in managing a patient’s medical problem

g Performs one or more years of training in a specialty area while working at a hospital (medical center)

Part III Multiple Choice Questions27. Chart chasing is eliminated when using this type of record system:

a. Paper-based systemb. Electronic health record systemc. Problem-oriented systemd. Integrated record system

28. Which of the following is NOT an incentive program for the adoption of EHR?a. PQRSb. MPFSc. ERxd. MU

29. Which MU stage focused on electronically capturing health information into coded format to track conditions, communicate information for care coordination and reporting of clinical quality measures and public health information?a. Stage 1b. Stage 2c. Stage 3d. Stage 4

30. The SOAP style of documentation that a physician uses to chart a patient’s progress in the health record means:a. signature, observations, assessment, and progressb. subjective, objective, assessment, and planc. symptoms, objective findings, and professional servicesd. subjective, opinions, assistance, and present illness

31. A physical examination of a patient performed by a physician is:a. descriptiveb. comprehensivec. subjectived. objective

32. During the performance of an external audit to review a medical practice’s health record system used to show deficiencies in documentation is called a/ana. SOAP systemb. Electronic recording systemc. Information record systemd. Point system



33. Which of these elements is a requirement for all levels of history?a. CCb. HPIc. ROSd. PFSH

34. When there is an underlying disease or other conditions are present at the time of the patient’s office visit, this is termed:a. mortalityb. continuityc. comorbidityd. complexity

35. Critical care is rendered:a. in the coronary care unitb. in the intensive care unitc. in the emergency roomd. all of the above

Part IV True/False Questions36. F A patient’s hospital discharge summary contains the discharge diagnosis but not the admitting

diagnosis.37. T An eponym should not be used when a comparable anatomic term can be used in its place. 38. F If the phrase “rule out” appears in a patient’s health record in connection with a disease, then

code the condition as if it existed.39. T During a prospective review or prebilling audit, all procedures or services and diagnoses listed on

the encounter form must match the data on the insurance claim form. 40. F Both civil and criminal subpoenas can be served via a fax machine.41. T Willful disregard of a subpoena is punishable as contempt of court.42. F Based on Medicare Conditions of Participation, hospitals must retain medical records for a period of

at least 4 years.43. T Assigned insurance claims for Medicaid and Medicare cases must be kept for a period of 7 years.44. T If a patient fails to make payment on an overdue account, the physician has the right to formally

withdraw from providing care to the patient.45. F There are very few circumstances that an insurance biller may be faced with when executing their

job duties that may lead a case of lawsuit.



Assignment 4-2 Review Diagnostic Terminology and AbbreviationsIn the Handbook, review Table 4-1 and anatomic figures, as well as Appendix A in the Workbook, which has a list of abbreviations and symbols.

1. d Taking or letting out fluids from a body part a. alteration

e Act of cutting out b. bypass

a Modifying a body part without affecting function c. control

f Taking out or off a device from a body part d. drainage

c Stop or attempt to stop bleeding e. excision

b Altering the route of passage with anastamoses f. removal

2. Write in the meaning for these abbreviations and/or symbols commonly encountered in a patient’s medical record:RLQ right lower quadrantDC dischargeWNL within normal limitsR/O rule outURI upper respiratory infectioncwith

3. When documenting incisions, the unit of measure for length should be listed in centimeters (cm).

Multiple Choice Questions 4. If a physician called and asked for a patient’s medical record STAT, what would he or she mean?

a. The physician wants a statistic from a patient’s record.b. The physician wants the record delivered on Tuesday.c. The physician wants the record delivered immediately.

5. If a physician asks you to locate the results of the last UA, what would you be searching for?a. a urinalysis reportb. an x-ray report of the ulnac. uric acid test results

6. If a physician telephoned and asked for a copy of the last H&P to be faxed, what is being requested?a. heart and pulmonary findingsb. H2 antagonist test resultsc. a history and physical

7. If a hospital nurse telephoned and asked you to read the results of the patient’s last CBC, what would you be searching for?a. carcinoma basal cell reportb. complete blood countc. congenital blindness, complete report

8. If you were asked to make a photocopy of the patient’s last CT, what would you be searching for?a. chemotherapy recordb. connective tissue reportc. computed tomography scan



Assignment 4–3 Critical Thinking: Solve an Office Problem

1. A patient comes into the office for treatment. He does not return, because he is dissatisfied with Dr. Practon’s treatment. Is it necessary to keep his records when he obviously will not return? Yes. Why? Records must be kept as required by state law for a certain time period. (Note: Records of a dissatisfied patient should be kept indefinitely because of the possibility of a lawsuit at a later date or to prevent a lawsuit.)

For additional critical thinking assignments, refer to the Lesson Plans and Lecture Outlines section of this TEACH Manual for Chapter 4.

Assignment 4–4 Abstract Subjective Observations and Objective Findings from Patient RecordsCASE STUDY 1

Mrs. Smith is 25 years old and was brought into the emergency department of College Hospital with complaints of difficulty in breathing and chest pain. Her vital signs show an elevated temperature of 101° F and pulse rate of 90. Respirations are labored at 30/min. BP is 140/80. Her skin is warm and diaphoretic (perspiring). She states, “This condition has been going on for the past 3 days.”

Subjective observations: Difficulty breathing and chest pain for 3 days

Objective findings: Temperature 101° F, pulse 90, respirations labored, 30/min, BP 140/80, skin warm and diaphoretic

CASE STUDY 2

Mr. Jones is 56 years old and was admitted to the hospital with chest pain and elevated pulse and blood pressure. His skin is cold and clammy.

Subjective observations: Chest pains

Objective findings: Elevated pulse and blood pressure, skin cold and clammy

CASE STUDY 3

You are assisting the radiology technician with Sally Salazar, a 6-year-old Hispanic girl, who was brought into the pediatrician’s office with a suspected fracture of the right arm. Sally states she was “running at school, tripped on my shoelace, and fell.” She tells you her “arm hurts,” points out how “funny my arm looks,” and starts to cry. You notice her arm looks disfigured and is covered with dirt. Sally is cradling her arm against her body and is unwilling to let go because “it’s going to fall off.”

Subjective observations: Right arm hurts and arm looks funny

Objective findings: Right arm looks disfigured and dirty

CASE STUDY 4

You are working in the business office of College Hospital. A former patient in your hospital comes in complaining of his billing. He states he was never catheterized, never had any of the medications listed on his itemized bill, and has “never been in this hospital for that length of time.” His face is red, his voice is gradually getting louder, and you notice he is standing with the aid of crutches because his left leg is in a full cast.

Subjective observations: Was never catheterized, never had any medications listed on bill, had never been in the hospital for that length of time

Objective findings: Face is red, voice gradually getting louder, patient standing with aid of crutches because left leg is in a full cast



Assignment 4–5 Review of a Patient Record1. Location: In what body system is the sign or symptom occurring?

Response: Genitourinary system2. Quality: Is the symptom or pain burning, gnawing, stabbing, pressure-like, squeezing, fullness?

Response: Pressure-like3. Severity: In this case, how would you rank the symptom (how was distress relieved) or pain (slight,

mild, severe, persistent)? Response: Voiding difficulty was relieved by patient being catheterized, only 50 cc output

4. Duration: How long has the symptom been present or how long does it last? Response: Has had problem with voiding difficulty since 9-5-20XX

5. Timing: When does (do) a sign(s) or symptom(s) occur (AM, PM, after or before meals)? Response: During the night; poor urinary output in lying down (supine) position

6. Context: Is the pain/symptom associated with big meals, dairy products, etc.? Response: No comments for context

7. Modifying factors: What actions make symptoms worse or better? Response: Voiding difficulty lying down, and voiding pattern improved while standing and sitting

8. Associated signs and symptoms: What other system or body area produces complaints when the presenting problem occurs? (Example: chest pain leads to shortness of breath.) Response: No other system involved other than genitourinary system (poor urinary output)

Assignment 4–6 Key a Letter of WithdrawalWording will vary depending on how much information is included in the patient’s medical record.







Assignment 4–7 Key a Letter to Confirm Discharge by the PatientWording will vary depending on how much information is included in the directions.




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s3.amazonaws.com · Web viewin the emergency room all of the above Part IV True/False Questions F A patient’s hospital discharge summary contains the discharge diagnosis but not