HAC Patient Assessment & Documentation 2

Question 1

Which documentation principle requires that entries be recorded as close to the time of the event as possible?

Accepted Answer

Timeliness

Answer

Accuracy

Answer

Legibility

Answer

Completeness

Question 2

In a SOAP note, what information belongs in the 'O' (Objective) section?

Accepted Answer

Measurable clinical findings such as vital signs and lab results

Answer

Patient's reported symptoms

Answer

Clinician's interpretation of the problem

Answer

Proposed treatment plan

Question 3

Which of the following best describes the purpose of a problem list in a patient's medical record?

Accepted Answer

Summarizes active and past health conditions for continuity of care

Answer

Tracks all medications prescribed during hospitalization

Answer

Provides a chronological log of nursing assessments

Answer

Lists all diagnostic tests ordered by physicians

Question 4

A healthcare analyst notices that a clinician's documentation consistently lacks specificity regarding wound descriptions. This most directly impacts which quality metric?

Accepted Answer

Coding accuracy and case mix index

Answer

Patient satisfaction scores

Answer

Length of stay calculations

Answer

Staff productivity rates

Question 5

What is the primary function of clinical documentation improvement (CDI) specialists?

Accepted Answer

Querying providers to clarify and complete clinical documentation

Answer

Entering physician orders into the EHR

Answer

Auditing patient billing statements for errors

Answer

Scheduling follow-up appointments for discharged patients

Question 6

Under HIPAA, which of the following is NOT considered a minimum necessary standard violation?

Accepted Answer

A treating physician reviewing a patient's complete chart before surgery

Answer

Sharing a patient's full medical history with a marketing firm

Answer

A nurse accessing records of a patient not under their care out of curiosity

Answer

Emailing unencrypted patient data to an unauthorized recipient

Question 7

Which assessment tool uses a 0–10 numeric scale most commonly associated with patient-reported pain documentation?

Accepted Answer

Numeric Rating Scale (NRS)

Answer

Glasgow Coma Scale

Answer

CAGE Questionnaire

Answer

PHQ-9