Ch. 2: The Health Record

Question 1

What is abstracting?

Answer 1

extracting data from the health record

Question 2

What is the chief complaint?

Answer 2

the reason, in the patient’s own word, for presenting to the hospital

Question 3

What is comorbidities?

Answer 3

preexisting diagnoses or conditions that are present on admission

Question 4

What is a consultant?

Answer 4

healthcare provider who is asked to see the patient to provide expert opinion outside the expertise of the requester

Question 5

What is a healthcare provider?

Answer 5

person who provides care to a patient

Question 6

What does hybrid mean?

Answer 6

a combination of formats producing similar results (i.e. paper and electronic records)

Question 7

What does integral mean?

Answer 7

essential part of a disease process

Question 8

What is a physician?

Answer 8

licensed medical doctor

Question 9

What is a principal diagnosis?

Answer 9

the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care

Question 10

What are progress notes?

Answer 10

daily recordings by healthcare providers of patient progress

Question 11

Every patient encounter must have a health record (True/False)

Answer 11

True

Question 12

The operative report should be written or dictated immediately following the procedure (True/False)

Answer 12

True

Question 13

List five purposes of a health record.

Answer 13

1. describes a patient’s health history, 2. serves as a method of communication for health care professionals, 3. serves as a legal document, 4. serves as a data source, 5. serves as a resource for health care education

Question 14

Name an advantage of an electronic patient record.

Answer 14

multiple users can access the record at the same time

Question 15

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

Answer 15

The Joint Commission, previously known as the Joint Commission on Accreditation of Healthcare Organizations

Question 16

List five elements requirements by the UHDDS.

Answer 16

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, diagnoses, procedures and dates, external cause of injury, birth weight of neonate, disposition of patient, source of payment, charges

Question 17

Where in the record would you find the chief complaint?

Answer 17

The chief complaint cant be found in almost any progress note but is most often found in the Emergency Record or in the Admission History and Physical. It is the reason in the patient’s own words for presenting to the hospital.

Question 18

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 18

The physician orders or medication administration report (MAR) would be the place to look for the discontinuation of drugs.

Question 19

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

Answer 19

The progress notes would show a patient’s daily progress in the hospital.

Question 20

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

Answer 20

The anesthesia record and operative report will contain documentation of blood loss during surgery

Question 21

What is the most important definition a coder should know?

Answer 21

The definition of principle diagnosis is “the condition after study found to be chiefly responsible for occasioning the admission to the hospital.”

Question 22

What determines an MS-DRG?

Answer 22

The MS-DRG is driven by the principal diagnosis along with the principle procedure.

Question 23

What is the principal diagnosis in the following scenario?
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 23

GERD

Question 24

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 24

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

Question 25

List five reasons why a secondary diagnosis might be reported.

Answer 25

If the secondary diagnosis meets one of the following criteria, it should be coded as clinical evaluation, therapeutic treatment, diagnostic procedure performed, extended length of the hospital stay, or increased nursing care or monitoring

Question 26

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 26

Yes, a code should be assigned for seizure disorder because the patient is currently being treated with Tegretol.

Question 27

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 27

Yes, urinary retention is documented by the physician and is requiring increased nursing care by monitoring urinary output and insertion of a Foley catheter.

Question 28

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 28

Yes, because Parkinson’s disease is one of the chronic conditions that are reported because patients are evaluated or monitored even though they are not specifically treated.

Question 29

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

Answer 29

just the gastroenteritis because the diarrhea and vomiting are symptoms of gastroenteritis

Question 30

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 30

The diagnostic procedure is the principal procedure.

Question 31

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

Answer 31

The discharge summary, if available, because it summarizes the events of the hospital stay

Question 32

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

Answer 32

No (or not necessarily). The coder must abide by the definition of principal diagnosis. Especially during a long stay, a physician might list the most current diagnoses rather that the reason the patient was admitted

Question 33

What does TJC stand for?

Answer 33

The Joint Commission, formerly known as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

Question 34

What does UHDDS stand for?

Answer 34

Uniform Hospital Discharge Data Set

Question 35

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

Answer 35

Operative Report and Admission History and Physical

Question 36

What does the term “integral” mean?

Answer 36

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

Question 37

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

Answer 37

The emergency record, if applicable, or in the physician’s admission orders or history and physical

Question 38

Name one reason why a coder would query a physician.

Answer 38

Reasons for querying could include unclear or questionable diagnosis, evidence of treatment but no diagnosis, to determine if a condition is due to a postoperative complication, to determine if an organism is the cause of a disease, to determine a more specific site or diagnosis, of for POA status

Question 39

The best place in the record to find the patient’s history is in the ()

Answer 39

History of the present illness (H&P) and past medical/surgical history (H&P)

Question 40

The beginning of the patient’s story is usually the discharge summary. True/False

Answer 40

False. The beginning of a patient’s story is often the Emergency Record or the Admission History and Physical

Question 41

It is permissible for a coder to use documentation provided by an interventionalist. True/False

Answer 41

True. An interventionalist is a physician.

Question 42

Once a physician answers a coding question, it should be thrown in the trash.

Answer 42

False. When a physician answers a query, this should become a permanent part of the record.

Question 43

Physician queries should only have enough room for a physician to sign and date True/False

Answer 43

False. There should be room for signing and dating as well as response; coder ID, and patient information such as name, MRN, admit date, and date of query.

Question 44

When a coding question is asked, it is very important that the financial impact of the response is included. True/False

Answer 44

False. This should never be included.

Question 45

It is important that the date and the identity of the physician be included for every note. True/False

Answer 45

True

Question 46

It is important for the record to include documentation that supports a code used in billing. True/False

Answer 46

True

Question 47

Documentation from a physician consultant cannot be used to assign codes. True/False

Answer 47

False. A consultant is a medical doctor.

Question 48

A principal diagnosis is one of the elements that determine an MS-DRG. True/False

Answer 48

True

Question 49

An example of a diagnostic procedure is an MRI. True/False

Answer 49

True

Question 50

Surgery can be a form of therapeutic treatment. True/False

Answer 50

True