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1. Documentation regarding a patient's marital status, dietary, sleep, and exercise
patterns, use of coffee, tobacco, alcohol, and other drugs may be found in the _____________. A. Physical examination record B. History record C. Operative report D. Radiological report Explanation The correct answer is history record. A patient's marital status, dietary habits, sleep patterns, exercise routines, and substance use are typically documented in their history record. This record includes information about the patient's past medical history, family history, social history, and lifestyle factors that may be relevant to their current health condition. The history record provides valuable information for healthcare providers to assess the patient's overall health and make appropriate treatment decisions. Step 1: Understand the Question The question asks where specific personal and lifestyle details about a patient are documented, such as marital status, dietary habits, sleep and exercise patterns, and substance use. Step 2: Analyze the Options A. Physical examination record
Incorrect : The physical examination record focuses on objective findings observed during a
physical assessment, such as vital signs, inspection, palpation, auscultation, and other clinical measurements. It does not include social or lifestyle information. B. History record
Correct : The history record contains detailed documentation of the patient's:
o Social history : Marital status, substance use (e.g., tobacco, alcohol, drugs), and
lifestyle habits (e.g., exercise, sleep patterns).
o Medical history : Past illnesses, surgeries, and family history.
o This record provides context for understanding the patient's overall health and factors
influencing their condition. C. Operative report
Incorrect : The operative report is a detailed account of a surgical procedure, including the
techniques used, findings, and outcomes. It does not address personal or lifestyle factors. D. Radiological report
Incorrect : A radiological report documents findings from imaging studies (e.g., X-rays, MRIs,
CT scans) and does not include lifestyle or social history. Step 3: Verify with the Explanation The explanation confirms that the history record is the correct answer, as it includes personal and social details that inform the patient’s care plan. This aligns with the purpose of the history record in gathering comprehensive patient information. Final Answer Correct Answer: B. History record Rationale : A patient's marital status, dietary habits, sleep and exercise patterns, and substance use are part of the social history , which is documented in the history record. This information helps healthcare providers evaluate factors that may impact the patient’s health and treatment plan.
2. A patient with known COPD and hypertension under treatment was admitted to the hospital with symptoms of a lower abdominal pain. He undergoes a laparoscopic appendectomy and develops a fever. The patient was subsequently discharged from the hospital with a principal diagnosis of acute appendicitis and secondary diagnoses of post-operative infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA? A. Postoperative infection B. Appendicitis C. COPD
D. Hypertension Explanation The patient developed a fever after undergoing a laparoscopic appendectomy, indicating a possible post-operative infection. Since the infection occurred after the surgery, it should not be tagged as present on admission (POA), as it was not present at the time of admission. Therefore, the correct answer is "Postoperative infection. Step 1: Understand the Question The question focuses on identifying which diagnosis should not be tagged as Present on Admission (POA). POA is defined as any condition that exists at the time of admission to the hospital. Conditions that develop after admission (such as post-operative complications) are not considered POA. Step 2: Analyze the Patient Case The patient’s medical case includes:
1. Primary diagnosis: Acute appendicitis (condition requiring laparoscopic appendectomy).
- Secondary diagnoses: Post-operative infection: Developed after the surgery. COPD: Chronic condition, known before admission. Hypertension: Chronic condition, known before admission. Step 3: Analyze the Options A. Postoperative infection
Correct : The infection developed after the laparoscopic appendectomy. Since it was not
present at the time of admission, it does not meet the criteria for POA. B. Appendicitis
Incorrect : Acute appendicitis was the reason for the patient’s hospital admission and was
clearly present at admission. It should be tagged as POA. C. COPD
Incorrect : Chronic obstructive pulmonary disease (COPD) is a pre-existing condition, known
before admission. It was present at admission and should be tagged as POA. D. Hypertension
Incorrect : Hypertension is also a pre-existing condition under treatment and was present at
the time of admission. It should be tagged as POA. Step 4: Explanation and Confirmation Per POA guidelines, conditions that develop after admission (e.g., complications like a post-operative infection) are not marked as POA. This aligns with the explanation that the infection developed post- surgery, making postoperative infection the correct answer. Final Answer Correct Answer: A. Postoperative infection Rationale : A post-operative infection developed after the surgery, so it does not meet the criteria for being present on admission (POA). Other conditions, such as acute appendicitis, COPD, and hypertension, were present at admission and should be tagged as POA
3. Which of the following would not be found in a medical history? A. Chief complaint B. Vital signs C. Present illness D. Review of systems Explanation Vital signs would not be found in a medical history. A medical history typically includes information about the patient's past and current medical conditions, medications, allergies, surgeries, and family medical history. It also includes details about the patient's chief complaint, present illness, and review of systems. Vital signs, on the other hand, are measurements of the body's basic functions, such as heart rate, blood pressure, temperature, and respiratory rate. While vital signs are important for assessing a patient's current health status, they are typically recorded separately and not included in the medical history.
Incorrect :
o The consent for the operative procedure is required before surgery, but the
anesthesia report and surgical report are created after the surgery to document the administration of anesthesia and the details of the operation. B. Consent for operative procedure, history, physical examination Correct:
o Consent for operative procedure : Confirms the patient understands and agrees to
the procedure, including risks, benefits, and alternatives.
o History and physical examination (H&P): Required to evaluate the patient’s health
and suitability for surgery. The H&P must be documented and updated within 30 days before the procedure. C. History, physical examination, anesthesia report Incorrect:
o While the history and physical examination are required, the anesthesia report is
not prepared until after surgery. D. Problem list, history, physical examination Incorrect :
o The problem list is a summary of the patient’s known medical conditions but is not
explicitly required before surgery. It does not replace the need for consent for the operative procedure. Step 3: Explanation and Confirmation Before surgery, the patient's medical record must include:
- Consent for the operative procedure : This ensures legal and ethical compliance by obtaining informed consent.
- History and physical examination : These provide a comprehensive assessment of the patient's health and identify any risks or contraindications for surgery. The explanation provided confirms that Option B meets the requirements, as these documents are necessary to ensure patient safety and compliance with preoperative standards. Final Answer Correct Answer: B. Consent for operative procedure, history, physical examination Rationale : These documents are required to assess patient readiness for surgery and to obtain their informed consent, fulfilling both clinical and legal obligations. 5. Which of the following reports include names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed. a) Operative report b) Anesthesia report c) Pathology report d) Laboratory report Explanation The operative report includes the names of the surgeon and assistants, the date of the procedure, the duration of the procedure, and a description of the procedure itself, including any specimens that were removed. This report provides a detailed account of the surgical procedure and is used for documentation and communication purposes. Anesthesia report focuses on the administration of anesthesia during the procedure, pathology report provides information about the examination of tissues for diagnosis, and laboratory report includes test results. Step 1: Understand the Question The question is asking which report documents specific details about a surgical procedure, including the names of the surgeon and assistants, the date, duration, and a description of the procedure, as well as any specimens removed. Step 2: Analyze the Options A. Operative report
Correct :
o The operative report is a detailed document prepared by the surgeon after a surgical
procedure.
o It includes:
Names of the surgeon and assistants.
Date and duration of the procedure.
Detailed description of the procedure performed.
Specimens removed (if applicable).
o This report is critical for documentation, legal purposes, and communication among
healthcare providers. B. Anesthesia report
Incorrect:
o The anesthesia report focuses on the anesthesia administered during the surgery,
including dosages, types of anesthetic used, and the patient’s response to anesthesia. C. Pathology report
Incorrect:
o The pathology report provides information about the examination and analysis of
specimens (e.g., tissues or cells) removed during surgery to aid in diagnosis. It does not include surgical details such as the names of the surgeon or the procedure duration. D. Laboratory report
Incorrect:
o The laboratory report includes results from diagnostic tests, such as blood work or
urinalysis, and does not document surgical procedures or their details. Step 3: Explanation The operative report is the standard document for recording all details of a surgical procedure. It serves as a comprehensive record of the surgery, including procedural specifics, participants, and outcomes. Other reports (anesthesia, pathology, laboratory) focus on specific aspects but do not encompass all the details listed in the question. Final Answer Correct Answer: A. Operative report Rationale : The operative report is the primary document for recording the names of the surgical team, the procedure date and duration, a detailed description of the surgery, and any specimens removed. It is essential for communication, legal documentation, and patient care continuity.
6. Identify the acute-care record report where the following information would be found: The patient is well-developed, obese male who does not appear to be in any distress, but has considerable problem with mobility. He has difficulty rising up from a chair and he uses a cane to ambulate. VITAL SIGNS: His blood pressure today is 158/86, pulse is 80 per minute, weight is 204 pounds (which is 13 pounds below what he weighed in April). He has no pallor. He has rather pronounced shaking of his arms, which he claims is not new. NECK: Showed no jugular venous distension. HEART: Very irregular. LUNGS: Clear. EXTREMITIES: Show edema of both legs. a. Discharge summary b. Medical history c. Medical laboratory report d. Physical examination Explanation The given information describes the physical condition of the patient, including their appearance, mobility issues, vital signs, and specific observations such as shaking arms and leg edema. This information is typically recorded during a physical examination, where a healthcare provider assesses the patient's overall health and identifies any abnormalities or concerns. The physical examination report would include these details, making it the correct answer. Step 1: Understand the Question The question asks where in an acute-care record the described patient information would be documented. The details include observations about the patient’s general condition, vital signs, and system-specific findings (e.g., heart, lungs, extremities). Step 2: Analyze the Options A. Discharge summary
Incorrect :
o The discharge summary includes a summary of the patient's hospital stay,
diagnoses, treatments, and discharge instructions, but it does not contain detailed information about tissue samples or lab results. B. Medical history
Incorrect :
o The medical history includes details about the patient’s past medical conditions,
surgeries, family history, and lifestyle. It does not include descriptions of laboratory specimens. C. Medical laboratory report
Correct :
o A medical laboratory report includes detailed findings from laboratory tests and
procedures, including the gross description of specimens (e.g., size, color, texture). The description provided in the question about the left lacrimal gland is exactly the type of information that would be documented in a pathology or laboratory report. D. Physical examination
Incorrect :
o A physical examination is focused on clinical findings observed by the healthcare
provider during an assessment of the patient’s body. It does not include detailed descriptions of tissue specimens or laboratory analysis. Step 3: Explanation The gross description of a tissue sample, such as the lacrimal gland, is part of a medical laboratory report , which provides a detailed analysis of specimens obtained during medical procedures (e.g., biopsies or surgical resections). Final Answer Correct Answer: C. Medical laboratory report Rationale : The description of the tissue sample (size, color, and other characteristics) is part of the medical laboratory report documenting the findings of laboratory tests, including pathology specimens.
- The clinical statement, "microscopic sections of the gallbladder reveals a surface lined by tall columnar cells of uniform size and shape" would be documented on which medical record form? a. Operative report a. Pathology report b. Discharge summary c. Nursing note Explanation This clinical statement would be documented on a pathology report. Pathology reports provide detailed information about the microscopic examination of tissue samples, including the identification of cells and any abnormalities or diseases present. In this case, the statement describes the appearance of the gallbladder lining, which is a microscopic finding that would be reported in a pathology report. Step 1: Understand the Question The question asks where a clinical statement describing the microscopic examination of the gallbladder would be documented. The statement describes the surface of the gallbladder being lined by tall columnar cells of uniform size and shape, which is a microscopic finding. Step 2: Analyze the Options A. Operative report
Incorrect :
o An operative report documents the details of the surgery performed, including the
type of procedure, the surgeon's findings, the technique used, and the condition of any tissues involved. It does not include microscopic descriptions of tissue samples. B. Pathology report
Correct :
o A pathology report provides detailed information about the microscopic examination
of tissue samples, including cellular structure, abnormalities, and other microscopic findings. The description provided in the question—about the gallbladder lining being lined with uniform columnar cells—is exactly the type of information that would be documented in a pathology report. C. Discharge summary
Incorrect :
o A discharge summary summarizes the patient's hospital stay, diagnoses,
treatments, and discharge instructions. It does not typically include detailed microscopic findings about tissue samples. D. Nursing note
Incorrect :
o A nursing note is used to document a nurse's observations, assessments, and
interventions related to the patient's care. It does not include detailed microscopic descriptions of tissue samples. Step 3: Explanation The clinical statement describes the microscopic examination of the gallbladder, specifically the appearance of the surface cells. This level of detail is typically found in a pathology report , which is where findings from lab tests, including tissue biopsies and other specimen examinations, are documented. Final Answer Correct Answer: B. Pathology report Rationale : The microscopic examination of the gallbladder, describing the surface lined by columnar cells, is a pathology finding and would be documented in a pathology report. 4o mini
9. Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for ______________. a) Performance improvement programs b) Billing and claims data processing c) Developing hospital discharge abstracting systems d) Developing individual care plans for residents Explanation Both HEDIS and the Joint Commission's ORYX program are designed to collect data for performance improvement programs. These programs aim to assess and enhance the quality of healthcare services provided by healthcare organizations. By collecting and analyzing data, these programs can identify areas of improvement and implement strategies to enhance patient outcomes, safety, and overall healthcare delivery. The data collected can be used to measure performance, compare it to established benchmarks, and implement evidence-based practices to improve the quality of care provided to patients. Step 1: Understand the Question The question is asking about the purpose of data collection by HEDIS (Healthcare Effectiveness Data and Information Set) and The Joint Commission's ORYX program. Step 2: Analyze the Options A. Performance improvement programs Correct : Both HEDIS and The Joint Commission's ORYX program are designed to collect data for performance improvement programs. These programs focus on measuring and improving healthcare quality by evaluating the effectiveness and outcomes of healthcare services. By collecting and analyzing data, these programs aim to identify opportunities for improvement, set benchmarks, and implement strategies to enhance the quality of care. B. Billing and claims data processing
documentation, whereas abstracting focuses on gathering and summarizing data from the medical record. C. Assembling a chronological set of data for an express purpose
Incorrect:
o While abstracting may involve assembling data, it focuses on summarizing relevant
information from the medical record, rather than creating a chronological set of data. This option is more general and doesn't capture the specificity of what abstracting entails. D. Conducting qualitative and quantitative analysis of documentation against standards and policy
Incorrect :
o This option describes the process of auditing or compliance review , not abstracting.
While audits may involve assessing the quality and completeness of documentation, abstracting is specifically about extracting relevant information for further use. Step 3: Explanation Abstracting refers to the process of reviewing a medical record and compiling pertinent information based on predefined criteria or data sets. The goal is to summarize essential elements of the record, such as diagnoses, treatments, and demographic information, for use in reporting, research, quality improvement, and billing. Final Answer Correct Answer: A. Compiling the pertinent information from the medical record based on predetermined data sets Rationale : Abstracting is the process of gathering specific, relevant data from a medical record according to predefined data sets. This data is then used for various purposes like reporting, research, and quality improvement.
Which of the following soil nutrients is most likely to be deficient in sandy soils and thus requires careful management for optimal crop production?
o A.
Nitrogen
o B.
Phosphorus
o C.
Potassium
o D.
Calcium Correct Answer A. Nitrogen Explanation Sandy soils tend to have low organic matter content and poor nutrient retention, making nitrogen particularly susceptible to leaching. As a result, nitrogen deficiency is common in sandy soils, and careful management practices, such as regular soil testing and appropriate fertilization, are required to ensure adequate nitrogen availability for optimal crop production. Rate this question: 1 0
According to ICD-9-CM, an elderly primigravida is defined as a woman who gives birth to her first child at the age of ______ or older:
o A.
o B.
o C.
o D.
Correct Answer B. 35 Explanation According to ICD-9-CM, an elderly primigravida is defined as a woman who gives birth to her first child at the age of 35 or older. This means that a woman who is 35 years old or above and is pregnant for the first time would be considered an elderly primigravida according to this classification system. Rate this question: 1 0
ICD-9-CM defines the "newborn period" as birth through the ___________ day following birth.
o A.
28th
o B.
14th
o C.
60th
o D.
30th Correct Answer A. 28th Explanation ICD-9-CM defines the "newborn period" as birth through the 28th day following birth. This classification is used to identify and categorize health care services and procedures related to newborns. The newborn period is critical for monitoring the health and development of infants during their initial days and weeks of life. Rate this question:
"Late pregnancy" (category code 645) is used to demonstrate that a woman is over _______________.
o A.
o B.
o C.
o D.
Correct Answer C. 40 Explanation The correct answer is 40. "Late pregnancy" is a category code used to indicate that a woman is over 40 weeks pregnant. This category is used to track and monitor the progress of a pregnancy that has gone beyond the expected due date. Rate this question: 1 0
D. Aspiration pneumonia Explanation When a patient with pneumonia inhales food, liquid, or oil, the most likely diagnosis would be aspiration pneumonia. Aspiration pneumonia occurs when foreign material, such as food or liquids, is inhaled into the lungs, leading to an infection. This can happen when a person has difficulty swallowing or when they accidentally inhale while eating or drinking. The symptoms of aspiration pneumonia can include coughing, shortness of breath, chest pain, and fever. It is important to diagnose and treat aspiration pneumonia promptly to prevent complications and further lung damage. Rate this question:
Where would a coder who needed to locate the histology of a tissue sample most likely find this information
o A.
Pathology report
o B.
Progress notes
o C.
Nurse's notes
o D.
Operative report Correct Answer A. Pathology report Explanation A coder who needs to locate the histology of a tissue sample would most likely find this information in a pathology report. Pathology reports are comprehensive documents that provide detailed information about the examination and analysis of tissues, including the histological findings. These reports are generated by pathologists who specialize in diagnosing diseases through the examination of tissue samples. Therefore, it is logical to assume that the histology of a tissue sample would be documented and accessible in a pathology report. Rate this question: 1 0
The coder notes the patient is taking prescribed Haldol. The final diagnoses on the progress notes include diabetes mellitus, acute pharyngitis, and malnutrition. What condition might the coder suspect the patient has and should query the physician?
o A.
Insomnia
o B.
Hypertension
o C.
Schizophrenia
o D.
Rheumatoid arthritis Correct Answer C. SchizopHrenia Explanation Based on the information provided, the coder notes that the patient is taking prescribed Haldol, which is an antipsychotic medication commonly used to treat schizophrenia. Therefore, the coder might suspect that the patient has schizophrenia and should query the physician for confirmation or further information. Rate this question: 1 0
Which organization developed the first hospital standardization program?
o A.
Joint Commission
o B.
American Osteopathic Association
o C.
American College of Surgeons
o D.
American Association of Medical Colleges Correct Answer C. American College of Surgeons Explanation The American College of Surgeons developed the first hospital standardization program. This organization is known for its efforts in improving the quality of surgical care and setting standards for hospitals to follow. Through their program, they aim to ensure that hospitals provide safe and effective surgical services to patients. Rate this question: 1 0
The hospital is revising its policy on medical record documentation. Currently, all entries in the medical record must be legible, complete, dated, and signed. The committee chairperson wants to add that, in addition, all entries must have the time noted. However, another clinician suggests that adding the time of notation is difficult and rarely may be correct since personal watches and hospital clocks may not be coordinated. Another committee member agrees and says only electronic documentation needs a time stamp. Given this discussion, which of the following might the HIM direct suggest?
o A.
Suggest that only hospital clock time be noted in clinical documentation
o B.
Suggest that only electronic documentation have time notated
o C.
Inform the committee that according to the Medicare Conditions of Participation all documentation must be authenticated and dated
o D.
Inform the committee that according to the Medicare Conditions of Participation only medication orders must include date and time Correct Answer C. Inform the committee that according to the Medicare Conditions of Participation all documentation must be authenticated and dated Explanation The correct answer suggests that the HIM director should inform the committee that according to the Medicare Conditions of Participation, all documentation must be authenticated and dated. This is the most appropriate response because it addresses the concern raised about adding the time of notation to all entries. Instead of focusing on the specific issue of time notation, the HIM director provides a broader guideline that ensures all entries are authenticated and dated, which is a requirement by Medicare. This response helps to maintain the integrity and accuracy of the medical record documentation. Rate this question:
When correcting erroneous information in a health record, which of the following is not appropriate?
o A.
Print "error" above the entry
addendum to the discharge summary. This is because the discharge summary was dictated on 1/26/2009, but the patient was actually discharged two days later. By requesting an addendum, the physician can provide an updated summary that accurately reflects the date of discharge. This ensures that the health record is complete and accurately represents the patient's information. Rate this question:
During an audit of health records, the HIM director finds that transcribed reports are being changed by the author up to a week after initial transcription. The director is concerned that changes occurring this long after transcription jeopardize the legal principle that documentation must occur near the time of the event. To remedy this situation, the HIM director should recommend which of the following?
o A.
Immediately stop the practice of changing transcribed reports
o B.
Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft form
o C.
Conduct a verification audit
o D.
Alert hospital legal counsel of the practice Correct Answer D. Alert hospital legal counsel of the practice Explanation The HIM director should recommend alerting hospital legal counsel of the practice because the concern is that changes made to transcribed reports long after initial transcription may jeopardize the legal principle that documentation must occur near the time of the event. By involving legal counsel, the hospital can ensure that they are following proper legal guidelines and avoid any potential legal issues that may arise from this practice. Rate this question: 2 1
During a review of documentation practices, the HIM director finds that nurses are routinely using the copy and paste function of the hospital's new EHR system for documenting nursing notes. In some cases, nurses are copying and pasting the objective data from the lab system and intake-output records as well as the patient's subjective complaints and symptoms originally documented by another practitioner. Which of the following should the HIM director do to ensure the nurses are following acceptable documentation practices?
o A.
Inform the nurses that "copy and paste" is not acceptable and to stop this practice immediately
o B.
Determine how many nurses are involved in this practice
o C.
Institute an in-service training session on documentation practices
o D.
Develop policies and procedures related to cutting, copying, and pasting documentation in the EHR system Correct Answer D. Develop policies and procedures related to cutting, copying, and pasting documentation in the EHR system Explanation The HIM director should develop policies and procedures related to cutting, copying, and pasting documentation in the EHR system. This will provide clear guidelines for nurses on acceptable documentation practices and ensure consistency in the use of the copy and paste function. Informing the nurses and stopping the practice
immediately may not be enough, as they may not fully understand the implications of their actions. Determining the number of nurses involved is important, but it does not address the root cause of the issue. Instituting an in-service training session may be helpful, but it is not as comprehensive as developing policies and procedures. Rate this question: 1 0
Who is responsible for writing and signing discharge summaries and discharge instructions?
o A.
Attending physician
o B.
Head nurse
o C.
Primary physician
o D.
Admitting nurse Correct Answer A. Attending pHysician Explanation The attending physician is responsible for writing and signing discharge summaries and discharge instructions. As the primary physician overseeing the patient's care, they have the most comprehensive understanding of the patient's condition and treatment plan. They are in the best position to provide accurate and detailed information regarding the patient's discharge, including any follow-up care instructions and medication prescriptions. The attending physician's signature ensures the validity and accountability of the discharge documentation. Rate this question:
Dr. Jones has signed a statement that all of her dictated reports should be automatically considered approved and signed unless she makes correction within 72 hours of dictating. This is called _____________.
o A.
Autoauthentication
o B.
Electronic signature
o C.
Automatic record completion
o D.
Chart tracking Correct Answer A. Autoauthentication Explanation Autoauthentication refers to the process of automatically approving and signing dictated reports by Dr. Jones unless she makes corrections within 72 hours. This means that the reports are considered valid and authenticated without the need for manual intervention or additional signatures. It streamlines the approval process and ensures efficiency in the documentation of Dr. Jones' reports. Rate this question:
The discharge summary must be completed within ________ after discharge for most patients but within __________ for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for less than __________ hours.
o A.
30 days / 48 hours / 24 hours
tracking purposes. It helps in maintaining accurate and reliable records, facilitating communication and coordination among different stakeholders, and ensuring patient safety and privacy. Rate this question: 3 0
What type of organization works under contract with the CMS to conduct Medicare and Medicaid certification surveys for hospitals?
o A.
Accreditation organizations
o B.
Certification organizations
o C.
State licensure agencies
o D.
Conditions of participation agencies Correct Answer C. State licensure agencies Explanation State licensure agencies work under contract with the CMS to conduct Medicare and Medicaid certification surveys for hospitals. These agencies are responsible for ensuring that hospitals meet the necessary standards and regulations to participate in these government healthcare programs. They conduct surveys to assess the quality of care provided by hospitals and determine their eligibility for Medicare and Medicaid reimbursement. These agencies play a crucial role in monitoring and enforcing compliance with federal regulations in the healthcare industry. Rate this question: 1 0
Which of the following specialized patient assessment tools must be used to Medicare-certified home care providers?
o A.
Patient Assessment Instrument
o B.
Minimum Data Set for Long-Term Care
o C.
Resident Assessment Protocol
o D.
Outcomes and Assessment Information Set Correct Answer D. Outcomes and Assessment Information Set Explanation The Outcomes and Assessment Information Set (OASIS) must be used by Medicare- certified home care providers. OASIS is a specialized patient assessment tool that is used to collect data on home health patients and is required by the Centers for Medicare & Medicaid Services (CMS). It includes a set of standardized questions and measures that assess the patient's health status, functional abilities, and outcomes of care. This information is used for quality measurement, payment, and regulatory purposes. The other options listed are not specific to home care providers or Medicare certification. Rate this question: 1 0
Identify the correct sequence and ICD-9-CM diagnosis code(s) for a patient with a scar on the right hand secondary to a laceration sustained two years ago.
o A.
o B.
o C.
o D.
Correct Answer B. 906. Explanation The correct ICD-9-CM diagnosis code for a scar on the right hand secondary to a laceration sustained two years ago is 906.1 (Late effect of open wound of hand without mention of complication). This code is used to report the long-term effects of an injury, such as a scar. The code 709.2 (Scar conditions and fibrosis of skin) is not used in this case because it is a less specific code and does not capture the fact that the scar is a late effect of a previous injury. Rate this question: 2 0
Identify the correct sequence and ICD-9-CM diagnosis code(s) for a patient with dysphasia secondary to an old cerebrovascular accident sustained one year ago.
o A.
o B.
o C.
o D.
Correct Answer A. 438.12, 784. Explanation The correct sequence and ICD-9-CM diagnosis code(s) for a patient with dysphasia secondary to an old cerebrovascular accident sustained one year ago is: 438.12, 784. 438.12 is the ICD-9-CM code for "Late effects of cerebrovascular disease; dysphasia." This code captures the primary diagnosis, which is the lasting effect (dysphasia) of the old cerebrovascular accident (CVA). 784.59 is the ICD-9-CM code for "Other speech disturbance." This code provides additional detail about the specific type of dysphasia the patient is experiencing. Rate this question:
Identify the correct ICD-9-CM diagnosis code(s) for a patient with nausea, vomiting, and gastroenteritis.
o A.
o B.
o C.
