Hospital: Documentation, Billing And Charting! Trivia Knowledge Quiz

2.

For a level 5 chart, what is the minimum number of elements of the HPI that need to be documented?

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4
5
6
7

Correct Answer

A. 5

Explanation

A level 5 chart in HPI (History of Present Illness) represents a comprehensive documentation of the patient's medical history, including symptoms, duration, severity, and associated factors. To ensure a thorough assessment, a minimum of 5 elements of the HPI need to be documented. This indicates that the healthcare provider must gather and record information about at least 5 relevant aspects of the patient's illness to meet the requirements of a level 5 chart.

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3.

For a level 4 chart, what is the minimum number of elements of the ROS that need to be documented?

1
2
3
4
5

Correct Answer

A. 3

Explanation

For a level 4 chart, the minimum number of elements of the ROS that need to be documented is 3. This means that at least 3 elements of the Review of Systems (ROS) need to be documented in the chart for it to meet the requirements of a level 4 chart.

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4.

For a level 5 chart, what is the minimum number of elements of the ROS that need to be documented?

6
7
8
9
10

Correct Answer

A. 10

Explanation

The level 5 chart refers to a specific type of chart in a certain context. In this context, the minimum number of elements of the ROS (Review of Systems) that need to be documented is 10. This means that in order to complete the level 5 chart, all 10 elements of the ROS must be documented.

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5.

Whatis the minimum number of elements of the PFSH that needs to be documented on every chart?

1
2
3
4

Correct Answer

A. 2

Explanation

The minimum number of elements of the PFSH that need to be documented on every chart is 2. This means that at least two elements from the Past Medical, Family History, and Social History sections should be documented for every patient.

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6.

For a level 4 chart, what is the minimum number of elements of the PE that need to be documented?

5
6
7
8
9

Correct Answer

A. 5

Explanation

For a level 4 chart, the minimum number of elements of the PE that need to be documented is 5. This means that at least 5 elements of the Process Engine (PE) need to be documented in order to create a level 4 chart.

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7.

For a level 5 chart, what is the minimum number of elements of the PE that need to be documented?

5
6
7
8
9

Correct Answer

A. 8

Explanation

For a level 5 chart, the minimum number of elements of the PE that need to be documented is 8.

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8.

For our documentation purposes, which is the best description of "supportive care":

IV FLUIDS
In reference to splints - implies we have restored function after an injury, however the patient will need follow up care with an orthopedist for additional manipulation and care.
In reference to splints - implies we have temporarily supported the injury, however the patient will need follow up care with an orthopedist for restorative care.
Calling Pastoral Services to console grieving family members

Correct Answer

A. In reference to splints - implies we have temporarily supported the injury, however the patient will need follow up care with an orthopedist for restorative care.

Explanation

The correct answer describes "supportive care" as temporarily supporting the injury with splints, but the patient will still need follow-up care with an orthopedist for restorative care. This means that while the splints provide temporary support, they do not fully restore function and additional care is needed to fully treat the injury.

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9.

For our documentation purposes, which is the best description "restorative care":

In reference to splints - implies we have temporarily supported the injury, however, the patient will need to follow up care with an orthopedist.
Patient has stopped vomiting with zofran and IV fluids, they are restored to their normal condition.
In reference to splints - implies we have repaired the injury and have provided definitive care, the patient does not need follow up with an orthopedist.

Correct Answer

A. In reference to splints - implies we have repaired the injury and have provided definitive care, the patient does not need follow up with an orthopedist.

Explanation

The correct answer is in reference to splints - implies we have repaired the injury and have provided definitive care, the patient does not need follow up with an orthopedist. This answer best describes "restorative care" in the context of splints. It suggests that the injury has been repaired and definitive care has been provided, indicating that the patient's condition has been restored and there is no need for further follow-up with an orthopedist.

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10.

Which of the following are indicators for critical care time (check all that apply):

Administering medications and IV fluids
Sepsis and Septic Shock
A 6 month old with a fever
Traumatic Brain Injury

Correct Answer(s)

A. Sepsis and Septic Shock
A. Traumatic Brain Injury

Explanation

B and D are the correct answers. We administer medications and IV fluids to non-critical patients all the time and a 6-month-old with a fever is not always critical, frequently it is a viral infection and the patient is sent home and advised to take Tylenol or Motrin.

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11.

Which of the following are indicators for critical care time (check all that apply):

Hemodynamic Insufficiency
Administering Cardizem for AFIB
Cardio Pulmonary Arrest with successful resuscitation
Acute Severe Pediatric Asthma

Correct Answer(s)

A. Hemodynamic Insufficiency
A. Administering Cardizem for AFIB
A. Cardio Pulmonary Arrest with successful resuscitation
A. Acute Severe Pediatric Asthma

Explanation

The correct answer is Hemodynamic Insufficiency, Administering Cardizem for AFIB, Cardio Pulmonary Arrest with successful resuscitation, Acute Severe Pediatric Asthma. These indicators are all situations where critical care time may be necessary. Hemodynamic insufficiency refers to a condition where the heart is unable to pump enough blood to meet the body's needs, requiring immediate intervention. Administering Cardizem for AFIB is a treatment for atrial fibrillation, a potentially life-threatening arrhythmia that may require critical care. Cardio Pulmonary Arrest with successful resuscitation is a situation where the patient experienced a cardiac arrest but was successfully revived, often requiring ongoing critical care. Acute Severe Pediatric Asthma is a severe respiratory condition in children that may require critical care interventions.

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12.

MD Doc Status numbers 1,2,3 are best described as:

Patient Seen; HPI complete; Labs Back
Patient Seen; HPI and ROS complete; MD has communicated plans for admission or disposition home
Patient Seen; HPI, ROS, PFSH and PE are complete; MD has communicated plans for admission or disposition home
Patient Seen; HPI, ROS, PFSH and PE are complete; All orders including labs, x-rays, CT's and sonograms are returned

Correct Answer

A. Patient Seen; HPI, ROS, PFSH and PE are complete; All orders including labs, x-rays, CT's and sonograms are returned

Explanation

The correct answer is "Patient Seen; HPI, ROS, PFSH and PE are complete; All orders including labs, x-rays, CT's and sonograms are returned." This option provides the most comprehensive description of the MD Doc Status numbers, indicating that all necessary assessments and orders have been completed and returned.

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13.

In terms of MD Doc Status, which best explains numbers 4 and 5?

MD has communicated disposition plans, the scribe is finishing chart; Chart is complete.
Chart is complete; Exit Care is printed
Chart is complete; Patient has been discharged
MD has reassessed the patient at least once; MD has communicated plans for disposition and the chart is complete.

Correct Answer

A. MD has communicated disposition plans, the scribe is finishing chart; Chart is complete.

Hospital: Documentation, Billing And Charting! Trivia Knowledge Quiz

For a level 4 chart, what is the minimum number of elements of the HPI that need to be documented?

Quiz Preview

For a level 5 chart, what is the minimum number of elements of the HPI that need to be documented?

For a level 4 chart, what is the minimum number of elements of the ROS that need to be documented?

For a level 5 chart, what is the minimum number of elements of the ROS that need to be documented?

Whatis the minimum number of elements of the PFSH that needs to be documented on every chart?

For a level 4 chart, what is the minimum number of elements of the PE that need to be documented?

For a level 5 chart, what is the minimum number of elements of the PE that need to be documented?

For our documentation purposes, which is the best description of "supportive care":

For our documentation purposes, which is the best description "restorative care":

Which of the following are indicators for critical care time (check all that apply):

Which of the following are indicators for critical care time (check all that apply):

MD Doc Status numbers 1,2,3 are best described as:

In terms of MD Doc Status, which best explains numbers 4 and 5?