CEHRS Clinical Documentation Management 3 — Questions and Answers
Question 1: Which type of clinical note summarizes a patient's hospital stay and is required before discharge in most accreditation standards?
- Progress note
- Discharge summary (Correct answer)
- Operative report
- History and physical
Correct answer: Discharge summary
The discharge summary provides a comprehensive overview of the patient's hospital course and must typically be completed within 30 days of discharge.
Question 2: An EHR system automatically populates a note with information from a previous visit without clinician review. This practice is called:
- Copy forward or cloning (Correct answer)
- Auto-authentication
- Concurrent coding
- Prospective documentation
Correct answer: Copy forward or cloning
Copy forward or cloning can compromise documentation integrity if outdated or inaccurate information is carried forward without review.
Question 3: Which standard body establishes medical record completion requirements that hospitals must meet for accreditation?
- CMS only
- The Joint Commission (TJC) (Correct answer)
- The American Medical Association
- The Office of Inspector General
Correct answer: The Joint Commission (TJC)
The Joint Commission sets record completion standards as part of its hospital accreditation requirements.
Question 4: A patient seen in the emergency department for chest pain is later found to have had a myocardial infarction. The diagnosis should be coded based on:
- The presenting complaint of chest pain only
- The confirmed diagnosis at the time of discharge (Correct answer)
- The first documented impression in triage
- The admitting physician's provisional diagnosis
Correct answer: The confirmed diagnosis at the time of discharge
For inpatient and ED visits resulting in admission, coding is based on the final confirmed diagnosis at the time of discharge.
Question 5: Which document type requires physician co-signature when documentation is completed by a medical student?
- Nursing assessment
- Progress notes authored by medical students (Correct answer)
- Radiology orders
- Pharmacy dispensing records
Correct answer: Progress notes authored by medical students
Medical students are not licensed providers, so their documentation requires co-signature by a supervising physician to be legally valid.
Question 6: The minimum length of time medical records for adults must be retained under most state and federal guidelines is:
- 3 years from the date of service
- 5 years from the date of service
- 10 years from the date of service (Correct answer)
- Permanently without exception
Correct answer: 10 years from the date of service
Most states require adult medical records to be retained for a minimum of 10 years, though requirements vary by state and record type.
Question 7: When a physician uses the term 'rule out' in a diagnosis, how should an outpatient record be coded?
- Code the confirmed diagnosis as stated
- Code the signs and symptoms, not the uncertain condition (Correct answer)
- Code 'rule out' as a confirmed diagnosis
- Leave the diagnosis field blank
Correct answer: Code the signs and symptoms, not the uncertain condition
In outpatient coding, uncertain diagnoses like 'rule out' are not coded; instead, the presenting signs and symptoms are coded.
CEHRS Clinical Documentation Management 3
Which type of clinical note summarizes a patient's hospital stay and is required before discharge in most accreditation standards?