Exam 2: The Health Record As the Foundation of Coding

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Match each definition to one of the following items. -GERD

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D

The patient history and physical need to be performed and documented within ___________ hours of admission for an inpatient encounter.

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Match each definition to one of the following items. -UHDDS

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C

Which of these is NOT considered a physician?

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Match each definition to one of the following items. -Health care providers

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Match each definition to one of the following items. -CMS

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Which report should be written or dictated immediately following a procedure?

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What is the goal of the physician query process?

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One of the most important aspects of developing an effective query form is the manner in which the form is worded.

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How long after admission is it required by TJC that the admission history and physical be completed?

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Match each definition to one of the following items. -Plan

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In some cases, a patient is ready to be discharged from the hospital, but at the last minute, the patient develops a condition that requires him or her to stay an additional night. An example of when a patient might have to stay an additional night is when the patient ____.

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Match each definition to one of the following items. -Chief complaint

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A query should contain all of the following items EXCEPT ____.

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Match each definition to one of the following items. -Current Procedural Terminology (CPT) and International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

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Which is the area of the record where the attending physicians, as well as physician consultants, give their directives to the house staff, nursing, and ancillary services?

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What does MRI stand for?

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Match each definition to one of the following items. -The Joint Commission

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Chronic conditions include all of the following EXCEPT ____.

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Abnormal findings (lab, x-ray, pathologic, and other diagnostic results) are always coded and reported when they are found.

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