HAC Patient Assessment & Documentation 3

Question 1

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

Accepted Answer

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

Answer

Adding a note immediately after care is given; no special labeling needed

Answer

Backdating an entry to match the time of care; standard practice

Answer

Deleting an incorrect entry and rewriting it; best practice for accuracy

Question 2

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

Accepted Answer

The uncertain diagnosis guideline

Answer

The first-listed diagnosis guideline

Answer

The principal diagnosis guideline

Answer

The comorbidity coding guideline

Question 3

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

Accepted Answer

Chest pain, unspecified

Answer

Acute myocardial infarction, unspecified

Answer

Possible angina pectoris

Answer

Probable cardiac event

Question 4

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

Accepted Answer

Healthcare power of attorney

Answer

Living will

Answer

Do-not-resuscitate order

Answer

Physician orders for life-sustaining treatment (POLST)

Question 5

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

Accepted Answer

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

Answer

Automatically corrects documentation errors

Answer

Encrypts patient data during transmission

Answer

Generates automated clinical decision alerts

Question 6

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

Accepted Answer

Both B and C

Answer

Braden Scale

Answer

Katz Index of Independence

Answer

Barthel Index

Question 7

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

Accepted Answer

Clinicians becoming overwhelmed by excessive CDI queries and reducing documentation quality

Answer

Patients refusing to answer repeated intake assessment questions

Answer

Coders submitting too many claim corrections to payers

Answer

EHR systems slowing down due to excessive data entry volume