Ch 2: Textbook Questions

Question 1

T/F: Every patient encounter must have a health record

Answer 1

True

Question 2

T/F: The operative report should be written or dictated immediately following the procedure

Answer 2

True

Question 3

List five purposes of a health record:

Answer 3

• 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

Question 4

Name an advantage of an electronic patient record.

Answer 4

Multiple users can access the record at the same time

Question 5

Name the nonfederal organization that requires reporting of data collected from the health record.

Answer 5

Uniform Hospital Discharge Data Set (UHDDS)

Question 6

List five elements required by the UHDDS.

Answer 6

• 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

Question 7

Where in the record would you find the chief complaint?

Answer 7

Emergency Room Record or Admission and Physical Examination

Question 8

If a physician was treating a patient with an antibiotic, where in the record would you look to see that treatment had been discontinued?

Answer 8

Physician Orders or Medication Report (MAR)

Question 9

Where in the record would you expect to see how the patient was progressing on a daily basis?

Answer 9

Progress Notes

Question 10

Where in the record might you look to find how much blood was lost during surgery?

Answer 10

Anesthesia Record or Operative Report

Question 11

What is the most important definition a coder should know?

Answer 11

Principal Diagnosis

Question 12

What determines an MS-DRG?

Answer 12

The principal diagnosis and the principal procedure

Question 13

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.”

Answer 13

Principal Diagnosis = GERD (gastroesophageal reflux disease)

Question 14

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?

Answer 14

No, the pneumonia is not coded because is is no longer an active condition that is being treated.

Question 15

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?

Answer 15

Yes, the seizure disorder should be coded because Tegretol is a treatment for seizures.

Question 16

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?

Answer 16

Yes, the urinary retention should be coded because it is currently being monitored.

Question 17

If a patient is not on any drugs for Parkinson’s, should a code be assigned for this diagnosis and why or why not?

Answer 17

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.

Question 18

If a patient presents with diarrhea and vomiting and the attending physician determines this to be gastroenteritis, what diagnosis/diagnoses should be assigned?

Answer 18

Gastroenteritis

Question 19

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?

Answer 19

The diagnostic procedure is the principal procedure

Question 20

When coding a record, where is the best place to begin?

Answer 20

Read the Discharge Summary

Question 21

If the discharge summary includes a list of diagnosis, should the coder automatically choose the first in the list as the principal diagnosis?

Answer 21

No

Question 22

What does TJC stand for?

Answer 22

The Joint Commission

Question 23

What does UHDDS stand for?

Answer 23

Uniform Hospital Discharge Data Set

Question 24

Which report in the record must be on the record within 24 hours?

Answer 24

Admission History and Physical Examination

Question 25

What does the term “integral” mean?

Answer 25

It means that if a condition is routinely associated with a disease process, it is not coded separately.

Question 26

Where in the record would a coder find the admitting diagnosis?

Answer 26

ER Record

Question 27

Name one reason why a coder would query a physician.

Answer 27

• 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

Question 28

The best place in the record to find the patient’s history is in the ______.

Answer 28

Admission History and Physical Examination

Question 29

T/F: The beginning of the patient’s story is usually the discharge summary.

Answer 29

False

Question 30

T/F: It is permissible for a coder to use documentation provided by an interventionalist.

Answer 30

True

Question 31

T/F: Once a physician answers a coding question, it should be thrown in the trash.

Answer 31

False

Question 32

T/F: Physician queries should have only enough room for a physician to sign and date.

Answer 32

False

Question 33

T/F: When a coding question is asked, it is very important that the financial impact of the response is included.

Answer 33

False

Question 34

T/F: It is important that the date and the identity of the physician be included for every note.

Answer 34

True

Question 35

T/F: It is important for the record to include documentation that supports a code used in billing.

Answer 35

True

Question 36

T/F: Documentation from a physician consultant cannot be used to assign codes.

Answer 36

False

Question 37

T/F: A principal diagnosis is one of the elements that determine an MS-DRG.

Answer 37

True

Question 38

T/F: An example of a diagnostic procedure is an MRI.

Answer 38

True

Question 39

T/F: Surgery can be a form of therapeutic treatment.

Answer 39

True