Patient Assessment & Documentation Flashcards

Which of the following is an example of a late entry in medical documentation, and how should it be handled?

Answer: Documenting missed care hours later; label as 'late entry' with current date/time

Late entries must be clearly labeled as such with the current date and time, not backdated, to preserve the integrity of the record.

Which ICD-10-CM guideline requires documentation of the reason for an outpatient visit to be coded to the highest degree of certainty?

Answer: The uncertain diagnosis guideline

The uncertain diagnosis guideline prohibits coding 'possible' or 'probable' diagnoses in outpatient settings; only confirmed or signs/symptoms should be coded.

A patient presents to the ED with chest pain. After workup, no diagnosis is confirmed. What should the coder document as the primary diagnosis?

Answer: Chest pain, unspecified

In outpatient settings, unconfirmed diagnoses cannot be coded; the presenting sign or symptom (chest pain) is coded instead.

Which element of an advance directive specifies the healthcare agent authorized to make decisions if the patient becomes incapacitated?

Answer: Healthcare power of attorney

A healthcare power of attorney designates a specific individual (agent) to make medical decisions when the patient lacks decision-making capacity.

In EHR systems, what is the purpose of an audit trail?

Answer: Records who accessed or modified a patient's record and when

Audit trails log all user activity within an EHR, including who viewed, entered, or modified records, supporting accountability and HIPAA compliance.

Which assessment framework uses the domains of Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) to evaluate functional status?

Answer: Both B and C

Both the Katz Index and the Barthel Index assess functional independence using ADL and IADL domains to guide care planning and discharge decisions.

Which of the following best describes 'query fatigue' in clinical documentation improvement?

Answer: Clinicians becoming overwhelmed by excessive CDI queries and reducing documentation quality

Query fatigue occurs when providers receive too many CDI queries, leading to burnout, generic responses, and ultimately declining documentation quality.