Exam 4: Medical Documentation and the Electronic Health Record

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Under the Federal False Claims Act, records that should be retained indefinitely include

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Match each of these terms, as they are used in a medical office, with the correct definition. -Character of the symptom/pain (burning, gnawing).

(Multiple Choice)
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Match each of these types of medical services to the correct definition. -Discussion with a patient, family, or both about diagnostic results and instructions for treatment.

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The acceptance of a subpoena by an authorized person is the equivalent of a subpoena being served personally.

(True/False)
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An electronic medical report is a

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Skin repairs are coded according to the sum of the length of the repairs in centimeters.

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Identify three ways that a physician may withdraw formally from further provision of care to a patient when the patient is noncompliant.

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When the physician provides critical care in the hospital emergency department, it is billed as emergency care.

(True/False)
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As a health insurance claims professional, you may be required to _______ information from a medical record to justify a Health Insurance Claim Form after professional services are rendered.

(Short Answer)
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A consultation may take place in a home, office, hospital, or extended care facility.

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An expanded problem-focused examination is a/an

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Match each of these types of medical services to the correct definition. -Providing similar services to the same patient by more than one physician on the same day.

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An age-appropriate review of past and current activities of the patient (e.g., smoking or use of alcohol) is known as a/an ____________________.

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Match each of these terms, as they are used in a medical office, with the correct definition. -Things done to make the symptom/pain worse or better.

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____________________ is a term used to define those providers or hospitals that have the capabilities and processes in place to actively use certified electronic health record technology.

(Short Answer)
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The chronologic recording of pertinent facts and observations about the patient's health is known as

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Match each of these types of medical services to the correct definition. -Intensive care provided during an acute life-threatening condition that requires constant bedside attention by the physician.

(Multiple Choice)
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The documentation of the patient's previous experiences with illnesses, operations, injuries, and treatments is known as the ____________________.

(Short Answer)
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The abbreviation HPI stands for ______________________________.

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The code for repair of a superficial laceration is found in the CPT Integumentary/Surgery section under the heading

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