HAC Patient Assessment & Documentation 3 — Questions and Answers
Question 1: Which of the following is an example of a late entry in medical documentation, and how should it be handled?
- Adding a note immediately after care is given; no special labeling needed
- Documenting missed care hours later; label as 'late entry' with current date/time (Correct answer)
- Backdating an entry to match the time of care; standard practice
- Deleting an incorrect entry and rewriting it; best practice for accuracy
Correct answer: Documenting missed care hours later; label as 'late entry' with current date/time
Late entries must be clearly labeled as such with the current date and time, not backdated, to preserve the integrity of the record.
Question 2: Which ICD-10-CM guideline requires documentation of the reason for an outpatient visit to be coded to the highest degree of certainty?
- The uncertain diagnosis guideline (Correct answer)
- The first-listed diagnosis guideline
- The principal diagnosis guideline
- The comorbidity coding guideline
Correct answer: The uncertain diagnosis guideline
The uncertain diagnosis guideline prohibits coding 'possible' or 'probable' diagnoses in outpatient settings; only confirmed or signs/symptoms should be coded.
Question 3: A patient presents to the ED with chest pain. After workup, no diagnosis is confirmed. What should the coder document as the primary diagnosis?
- Acute myocardial infarction, unspecified
- Chest pain, unspecified (Correct answer)
- Possible angina pectoris
- Probable cardiac event
Correct answer: Chest pain, unspecified
In outpatient settings, unconfirmed diagnoses cannot be coded; the presenting sign or symptom (chest pain) is coded instead.
Question 4: Which element of an advance directive specifies the healthcare agent authorized to make decisions if the patient becomes incapacitated?
- Living will
- Do-not-resuscitate order
- Healthcare power of attorney (Correct answer)
- Physician orders for life-sustaining treatment (POLST)
Correct answer: Healthcare power of attorney
A healthcare power of attorney designates a specific individual (agent) to make medical decisions when the patient lacks decision-making capacity.
Question 5: In EHR systems, what is the purpose of an audit trail?
- Automatically corrects documentation errors
- Records who accessed or modified a patient's record and when (Correct answer)
- Encrypts patient data during transmission
- Generates automated clinical decision alerts
Correct answer: Records who accessed or modified a patient's record and when
Audit trails log all user activity within an EHR, including who viewed, entered, or modified records, supporting accountability and HIPAA compliance.
Question 6: Which assessment framework uses the domains of Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) to evaluate functional status?
- Braden Scale
- Katz Index of Independence
- Barthel Index
- Both B and C (Correct answer)
Correct answer: Both B and C
Both the Katz Index and the Barthel Index assess functional independence using ADL and IADL domains to guide care planning and discharge decisions.
Question 7: Which of the following best describes 'query fatigue' in clinical documentation improvement?
- Clinicians becoming overwhelmed by excessive CDI queries and reducing documentation quality (Correct answer)
- Patients refusing to answer repeated intake assessment questions
- Coders submitting too many claim corrections to payers
- EHR systems slowing down due to excessive data entry volume
Correct answer: Clinicians becoming overwhelmed by excessive CDI queries and reducing documentation quality
Query fatigue occurs when providers receive too many CDI queries, leading to burnout, generic responses, and ultimately declining documentation quality.
HAC Patient Assessment & Documentation 3
Which of the following is an example of a late entry in medical documentation, and how should it be handled?