Medical Records Standards And Documentation Guidelines

Question 1

When utilizing templates to document in a medical record, what documentation must be included in the template?

a. A family history of relevant diseases.

b. All check boxes must be complete whether normal or abnormal,

c. The patient’s height and/or weight to verify there was a face-to-face visit.

d. Elaboration on abnormal findings.

Answer 1

d. Elaboration on abnormal findings.

Rationale: When providers use templates for documentation, they might have check boxes to indicate whether an exam of a body area or organ system is normal. In this case, any findings that are abnormal must have elaboration as to what is abnormal. It is helpful if the provider has a key explaining checklist symbols.

Question 2

In evaluation and management services, what does the S stand for in SOAP and what is included in this section?

Answer 2

Subjective; patient’s account of his or her symptoms and what, if anything has been done to relieve the symptoms.

Question 3

Which type of signature will CMS allow only in the case of a provider with a proven disablity affecting their ability to provide a signature?

Answer 3

Rubber Stamp

Rationale: The method used (e.g. handwritten or electronic) to sign an order or other medical record documentation for medical review purposes in determining coverage is not a relevant factor. The Centers for Medicare & Medicaid Services allows rubber stamps only in the case of a provider with a proven disability affecting their ability to provide a signature, but other carriers may still allow it.

Question 4

When a correction is made in an electronic health record, what must exist?

Answer 4

Reliable means to clearly identify the original content and the modified content.

Question 5

When a minor procedure is performed in the office, what is the documentation requirement?

Answer 5

The detail of the procedure can be included in the documentation for the office visit.

Question 6

What form is required to be obtained from the patient prior to completing a surgical procedure?

Answer 6

Informed consent

Question 7

Which type of provider is not required to dictate his or her own operative report?

a. Co-surgeon
b. Primary surgeon
c. Surgeons in a surgical team
d. Assistant surgeon

Answer 7

d. Assistant surgeon

Question 8

What must be included in a business associate agreement?

a. The permitted and required uses of PHI by the business associate.

b. There are no requirements for what is included in the business associate agreement.

c. The name of each person who will see the PHI.

d. Each record that is shared with the business associate must be identified individually, included names and dates of service.

Answer 8

a. The permitted and required uses of PHI by the business associate.

Rationale: The contract must describe the permitted and required uses of protected health information by the business associate, limit the business associate from using or further disclosing the protected health information (except where permitted by contract or required by law), and require the business associate to follow appropriate safeguards to prevent use or disclosure of the protected health information, except as expressly defined in the contract.

Question 9

When referring to radiological services, what is the requirement for the images obtained?

Answer 9

The actual images must be retained.

Rationale: Not only is it necessary to retain the actual images of radiologic services, it is also important that a written report is obtained, to include the indication for the study and to summarize the findings. An order or request for the study must also be retained.

Question 10

What program was established by HIPAA to combat fraud and abuse committed against all health plans, both public and private?

Answer 10

Health Care Fraud and Abuse Control Program

Question 11

What is considered protected health information (PHI)?

a. Individually identifiable health information.

b. Provider information submitted on a claim for payment.

c. Statistical information relating to a specific demographic area.

d. Health information that is randomly gathered for research purposes.

Answer 11

a. Individually identifiable health information.

Rationale: Protected health information is “individually identifiable health information.” It includes many common identifiers, such as demographic data, name, address, birth date, and social security number. It also includes information that relates to an individual’s past, present, or future physical or mental health or condition; the provision of health care to the individual; or, the past, present, or future payment for the provision of health care to the individual, which reasonably may be used to identify an individual.

Question 12

If a covered entity identifies a material breach of a business associate agreement, and it is not possible to cure the breach or end the violation, what should occur?

Answer 12

The contract must be terminated, and the problem reported to the HHS Office for Civil rights.

Question 13

What are healthcare institutions to do in the absence of clearly defined laws and regulations relating to the content of a medical record?

Answer 13

Establish their own standards.

Question 14

In evaluation and management services, what does the O stand for in SOAP and what is included in this section?

Answer 14

Objective; indicates the physical exam findings of the provider.

Question 15

What form is used to allow the release of their medical records?

Answer 15

Release of Information

Question 16

When a laboratory report has an abnormal finding, what should be documented?

Answer 16

Circle and sign the abnormal finding and address the abnormality in the diagnosis

Question 17

What is informed consent?

Answer 17

A way to indicate that a discussion between the patient and the provider took place about a patient’s condition and the treatment options available, to allow the patient an opportunity to ask questions and make an informed choice on his or her plan of treatment.

Question 18

When documenting physical therapy treatment encounter for Medicare, what should be documented for the modalities?

Answer 18

Each individual modality used with total duration of time in minutes.

Rationale: Treatment encounter notes for each treatment day and should include:
· Date of treatment
· Treatment, intervention, or activity
· Total timed treatment by individual modality and total treatment time in minutes (includes timed codes and untimed codes)
· Signature and professional identity of the qualified professional furnishing the treatment
· Additional information may include response to treatment or changes.

Question 19

Which section of an operative report would you expect to find the reason or medical necessity for the procedure?

Answer 19

Indication for surgery.

Question 20

According to the Joint Commission (JC) Official “Do Not Use” List, what would be considered an abbreviation that should not be used in a medical record and why?

a. IU; because it can be mistaken for IV or the number 10.

b. IV; because it can be mistaken for IU.

c. PRN; because it may be misunderstood to be a privacy issue.

d. HTN; because there should be more specification on the type of hypertension.

Answer 20

A. IU; because it can be mistaken for IV or the number 10.

Question 21

In an operative note, where should information be taken to ensure accurate assignment of a CPT® code?

Answer 21

From the body of the operative note.

Question 22

Which governing body is responsible for criminal prosecutions relating to the Privacy Rule?

Answer 22

Department of Justice

Question 23

What is the Health Care Fraud and Abuse Control Program?

Answer 23

A program established by HIPAA to combat fraud and abuse in healthcare.

Question 24

What form is used to record patient demographic information, insurance and financial information, and emergency contacts?

Answer 24

Patient registration form—This form gathers information needed to identify the patient and process claims and typically includes the date, patient demographic information (age, date of birth, address, social security number), insurance and financial information, and an emergency contact.

Question 25

What type of health plan is exempt from HIPAA?

Answer 25

Employer health plan that the employer solely establishes and maintains, with fewer than 50 participants.

Rationale: Health Plan covered entities are organizations that pay providers on behalf of an individual receiving medical care. These plans include health, dental, vision, and prescription drug insurers. Some examples include Health Maintenance Organizations (HMOs), Medicare, Medicaid, and Medicare supplement insurers, as well as employer, government, and church-sponsored group health plans. An exception is an employer who solely establishes and maintains the plan with fewer than 50 participants and is exempt. Two types of government-funded programs are not health plans. These are food stamps and community health centers. Insurers providing only worker’s compensation, automobile insurance, and property and casualty insurance are not considered to be health plans.

Question 26

Under what circumstance may providers use or disclose protected health information without patient consent?

Answer 26

Payment, treatment, or operations

Question 27

Which of the following is an example of information that may be transmitted electronically and covered under the privacy rule?

A. Appointment schedules
B. Physician credentials
C. Claim forms
D. Email

Answer 27

C. Claim forms

Question 28

What program was established by HIPAA to combat fraud and abuse committed against all health plans, both public and private?

Answer 28

Healthcare Fraud and Abuse Control Program

Question 29

Which governing body is responsible for criminal prosecutions relating to the Privacy Rule?

Answer 29

Department of Justice

Question 30

How long does Medicare’s Conditions of Participation (CoP) for hospitals require retention of medical records?

Answer 30

Five years after the closed cost report

Question 31

What are healthcare institutions to do in the absence of clearly defined laws and regulations relating to the content of a medical record?

Answer 31

Establish their own standards

Question 32

How must medical records be retained?

Answer 32

There are no specific requirements as to how the medical records must be retained. They may be kept in their original format or reproduced in a way that is legally acceptable. The most important component of retention is that the record is protected, to ensure the security and integrity of the records.

Question 33

CMS requires a legible identity for services provided/ordered. What type of signature has an exception for CMS?

A. Handwritten
B. Electronic
C. Rubber Stamp
D. All of the above are allowed by CMS without an exception

Answer 33

C. Rubber Stamp

Rationale: The Centers for Medicare & Medicaid Services allows rubber stamps only in the case of a provider with a proven disability affecting their ability to provide a signature.

Question 34

When utilizing templates to document in a medical record, what documentation must be included in the template?

Answer 34

Elaboration on abnormal findings

Question 35

What included on the patient registration form?

Answer 35

Information needed to identify the patient and process claims and typically includes the date, patient demographic information (age, date of birth, address, Social Security number), insurance and financial information, and an emergency contact.

Question 36

What is an Assignment of Benefits form?

Answer 36

An authorization form signed by the patient that allows their insurance carrier to pay the provider directly. Without this, the payment will go to the beneficiary and the provider will be required to collect payment from the beneficiary.

Question 37

What does an informed consent consist of?

Answer 37

• The patient’s diagnosis (if known)
• The nature and purpose of a proposed treatment/procedure
• Alternative treatments/procedures
• The associated risks and benefits
• The risk and benefits of not receiving the treatment/procedure.

Question 38

What does each letter in SOAP stand for?

Answer 38

S - Subjective
O - Objective
A - Assessment
P - Plan

Question 39

What does each letter in CHEDDAR stand for?

Answer 39

C - Chief Complaint
H - History of present illness
E - Exam
D - Details
D - Drugs and dosages
A - Assessment
R - Return visit information or referral

Question 40

What is the header of an operative note designed to identify?

Answer 40

-Patient name
-Date of surgery
-Preoperative diagnosis
-Postoperative diagnosis
-The procedure performed
-Primary surgeon
-Assistant surgeon(s)
-Anesthesia administered
-Anesthesiologist

Question 41

What is in the Indication section of an operative report?

Answer 41

The indication typically gives a brief history outlining the reasons for or medical necessity for the procedure.

Question 42

What is informed consent?

Answer 42

A way to indicate that a discussion between the patient and the provider took place about a patient’s condition and the treatment options available, to allow the patient an opportunity to ask questions and make an informed choice on his or her plan of treatment.

Question 43

Where should information be found in an operative note to ensure accurate assignment of a CPT® code?

Answer 43

From the body of the operative note

Question 44

When a minor procedure is performed in the office, what is the documentation requirement?

Answer 44

If a minor office procedure is performed during an evaluation and management service, the documentation for that procedure can be included in the notes for the evaluation and management service. It is not necessary to have a separate operative report. Documentation must clearly describe the procedure and show that it is separate from the E/M portion of the encounter.

Question 45

Which section of an operative report would you expect to find the reason or medical necessity for the procedure?

Answer 45

Indication for surgery

Question 46

What does a complete radiology report contain?

Answer 46

• Patient name
• Referring physician
• Date and time of study
• Patient history
• Reason for study
• Diagnostic and procedural statement
• Extent of exam (limited, complete)
• Number and type of views taken (bilateral, left, right)
• Contrast material used, as appropriate; including type, amount, and method of administration
• Separate description of each study performed on the patient.
• Recommendations for follow-up exam or additional studies needed
• Comparison of prior studies, as appropriate
• Indication of any limitations in study, such as poor image quality or poor patient prep
• Summary of conversations with other healthcare providers
• Findings, results, impressions, conclusions
• Signature of radiologist

Question 47

Must an order or request for a radiology study be retained in the patient file?

Answer 47

It is not necessary for the orders to be maintained in the patient file but must be maintained by the facility.

Question 48

The lab report should contain the following elements:

Answer 48

• Patient name and identification number
• Name of laboratory
• Name of physician or practitioner ordering the test
• Date and time of the collected specimen, and date and time of receipt
• Reason for an unsatisfactory specimen, if applicable
• Test or evaluation performed
• Result
• Date and time of report

Question 49

Documentation requirements for therapy services include:

Answer 49

• Evaluation and Plan of Care;
• Certification and recertification;
• Progress reports which provides justification for the medical necessity of treatment information; and
• Treatment encounter notes for each treatment day and should include:
• Date of treatment
• Treatment, intervention, or activity
• Total timed treatment by individual modality and total treatment time in minutes (includes timed codes and untimed codes)
• Signature and professional identity of the qualified professional furnishing the treatment
• Additional information may include response to treatment or changes.

Question 50

A therapy plan of care must contain:

Answer 50

-Diagnoses;
-Long term treatment goals;
-Type of rehabilitation therapy services (physical therapy, occupational therapy, or speech-language pathology) identifies each specific intervention, procedure, or modality, to support billing and verify correct coding;
-Amount of therapy—number of treatment sessions in a day;
-Duration of therapy—number of weeks or number of treatment sessions; and
-Frequency of therapy—number of treatment sessions in a week.
-Current functional limitations indicating severity of limitation and discharge goal functional limitation and projected severity of limitation.

Question 51

When referring to radiological services, what is the requirement for the images obtained?

Answer 51

Retain the actual images.

Not only is it necessary to retain the actual images of radiologic services, it is also important that a written report is obtained, to include the indication for the study and to summarize the findings. An order or request for the study must also be retained.

Question 52

What should be documented in the radiology report when contrast material is used?

Answer 52

The type and amount of contrast used, along with the route of administration.

Question 53

For therapy services, what is the reason for a progress note?

Answer 53

To provide justification for the medical necessity of treatment information.

Question 54

For each day of a physical therapy treatment encounter provided to a Medicare patient, what should be documented for the modalities?

Answer 54

Each individual modality used with total duration of time in minutes.

Question 55

Therapy treatment encounter notes for each treatment day and should include:

Answer 55

-Date of treatment
-Treatment, intervention, or activity
-Total timed treatment by individual modality and total treatment time in minutes (includes timed codes and untimed codes)
-Signature and professional identity of the qualified professional furnishing the treatment
-Additional information may include response to treatment or changes.

Question 56

The past history focuses on the patient’s prior medical treatments and can include:

Answer 56

-Prior major illnesses and injuries
-Prior operations
-Prior hospitalizations
-Current medications
-Allergies
-Age-appropriate immunization status
-Age-appropriate feeding/dietary status

Question 57

Social History identifies current and past patient activities, such as:

Answer 57

-Social status or living arrangements (if child, social status of parents)
-Employment status
-Occupational history
-Drug, tobacco, alcohol use (if child, exposure to second-hand smoke)
-Education level
-Sexual history
-Any social event/occurrence impacting patient’s condition