Ch 2: Textbook Questions Flashcards
T/F: Every patient encounter must have a health record
True
T/F: The operative report should be written or dictated immediately following the procedure
True
List five purposes of a health record:
- Describes the patient’s health history
- Serves as a method for clinicians to communicate regarding the plan of care for the patients
- Serves as a legal document of care and services provided
- Serves as a source of data
- Serves as a resource for healthcare practitioner education
Name an advantage of an electronic patient record.
Multiple users can access the record at the same time
Name the nonfederal organization that requires reporting of data collected from the health record.
Uniform Hospital Discharge Data Set (UHDDS)
List five elements required by the UHDDS.
- Personal Identifier
- Date of Birth
- Sex
- Race and Ethnicity
- Residence
- Hospital ID
- Admit Date
- Type of Admit
- Discharge Date
- NPI of operating and attending physician
- Diagnosis
- Procedures and dates
- External cause of injury
- Birth weight of neonate
- Disposition of patient
- Source of payment
- Charges
Where in the record would you find the chief complaint?
Emergency Room Record or Admission and Physical Examination
If a physician was treating a patient with an antibiotic, where in the record would you look to see that treatment had been discontinued?
Physician Orders or Medication Report (MAR)
Where in the record would you expect to see how the patient was progressing on a daily basis?
Progress Notes
Where in the record might you look to find how much blood was lost during surgery?
Anesthesia Record or Operative Report
What is the most important definition a coder should know?
Principal Diagnosis
What determines an MS-DRG?
The principal diagnosis and the principal procedure
Principal Diagnosis: “A patient is admitted to the hospital with extreme indigestion. A workup ensues, and the patient is found to have GERD (gastroesophageal reflux disease). Three days later, on the day of discharge, the patient is unable to speak. After undergoing MRI, the patient is found to have had a stroke.”
Principal Diagnosis = GERD (gastroesophageal reflux disease)
A patient is admitted to the hospital with an asthma attack. On his last admission 3 years ago, the diagnosis was community-acquired pneumonia. Is the pneumonia coded, and why or why not?
No, the pneumonia is not coded because is is no longer an active condition that is being treated.
The physician documents seizure disorder in the patient’s past medical history. The patient is receiving Tegretol, according to the list of medications. Should the seizure disorder be coded, and why or why not?
Yes, the seizure disorder should be coded because Tegretol is a treatment for seizures.
A patient has urinary retention after undergoing surgery documented in progress notes. The attending writes an order for the nursing staff to record urine output. The nurse inserts a Foley catheter. Should the urinary retention be coded, and if so, why or why not?
Yes, the urinary retention should be coded because it is currently being monitored.
If a patient is not on any drugs for Parkinson’s, should a code be assigned for this diagnosis and why or why not?
Yes, Parkinson’s should be coded because Parkinson’s disease is a chronic condition that is evaluated and monitored even though it may bot be specifically treated.
If a patient presents with diarrhea and vomiting and the attending physician determines this to be gastroenteritis, what diagnosis/diagnoses should be assigned?
Gastroenteritis
Which is the principal procedure, when a diagnostic procedure is performed for the principal diagnosis and a therapeutic procedure is performed for definitive treatment of a secondary diagnosis?
The diagnostic procedure is the principal procedure
When coding a record, where is the best place to begin?
Read the Discharge Summary
If the discharge summary includes a list of diagnosis, should the coder automatically choose the first in the list as the principal diagnosis?
No
What does TJC stand for?
The Joint Commission
What does UHDDS stand for?
Uniform Hospital Discharge Data Set
Which report in the record must be on the record within 24 hours?
Admission History and Physical Examination
What does the term “integral” mean?
It means that if a condition is routinely associated with a disease process, it is not coded separately.
Where in the record would a coder find the admitting diagnosis?
ER Record
Name one reason why a coder would query a physician.
- Unclear or questionable diagnosis
- Evidence of treatment but no diagnosis
- To determine if a condition is due to postoperative complication
- To determine if an organism is the cause of a diagnosis
- To determine a more specific site or diagnosis
- For POA (present on admission) status
The best place in the record to find the patient’s history is in the ______.
Admission History and Physical Examination
T/F: The beginning of the patient’s story is usually the discharge summary.
False
T/F: It is permissible for a coder to use documentation provided by an interventionalist.
True
T/F: Once a physician answers a coding question, it should be thrown in the trash.
False
T/F: Physician queries should have only enough room for a physician to sign and date.
False
T/F: When a coding question is asked, it is very important that the financial impact of the response is included.
False
T/F: It is important that the date and the identity of the physician be included for every note.
True
T/F: It is important for the record to include documentation that supports a code used in billing.
True
T/F: Documentation from a physician consultant cannot be used to assign codes.
False
T/F: A principal diagnosis is one of the elements that determine an MS-DRG.
True
T/F: An example of a diagnostic procedure is an MRI.
True
T/F: Surgery can be a form of therapeutic treatment.
True
