How To Read Medical Record Faster

1. We can code the visit as valid even if Patient name is not present.

True

False

The statement is false because the visit cannot be considered valid if the patient name is not present. The patient name is a crucial piece of information that is necessary for identification and record-keeping purposes. Without the patient name, it would be difficult to accurately track and document the visit, leading to potential errors and confusion in the healthcare system.

Explanation

The statement is false because the visit cannot be considered valid if the patient name is not present. The patient name is a crucial piece of information that is necessary for identification and record-keeping purposes. Without the patient name, it would be difficult to accurately track and document the visit, leading to potential errors and confusion in the healthcare system.

2. Which condition should be coded as directly submittal from the outpatient visit Assessment ?

Acute inpatient condition

History of condition

Probable, suspected

None of the above

The correct answer is "None of the above" because the question is asking for a condition that should be coded as directly submittal from the outpatient visit assessment. However, all the options provided (acute inpatient condition, history of condition, probable, suspected) do not fit this criteria. Therefore, the correct answer is none of the above.

Explanation

The correct answer is "None of the above" because the question is asking for a condition that should be coded as directly submittal from the outpatient visit assessment. However, all the options provided (acute inpatient condition, history of condition, probable, suspected) do not fit this criteria. Therefore, the correct answer is none of the above.

3. We can code directly submittal for PE section without MEAT.

True

False

This statement suggests that it is possible to submit the coding directly for the PE (Preservation Engineering) section without the need for MEAT (Materials Engineering and Testing). This implies that the coding requirements for the PE section do not require any input or testing related to materials engineering. Therefore, the answer is true.

Explanation

This statement suggests that it is possible to submit the coding directly for the PE (Preservation Engineering) section without the need for MEAT (Materials Engineering and Testing). This implies that the coding requirements for the PE section do not require any input or testing related to materials engineering. Therefore, the answer is true.

4. We can not code from family history even though meat is found.

True

False

The statement suggests that even though meat is found, we cannot code from family history. This implies that family history alone is not sufficient to determine or code something accurately. It could mean that other factors or information need to be considered in addition to family history in order to code correctly. Therefore, the correct answer is true.

Explanation

The statement suggests that even though meat is found, we cannot code from family history. This implies that family history alone is not sufficient to determine or code something accurately. It could mean that other factors or information need to be considered in addition to family history in order to code correctly. Therefore, the correct answer is true.

5. ROS is part of ?

Subjective

Objective

Medical Decision making

All of above

The correct answer is "Subjective" because ROS stands for Review of Systems, which is a subjective assessment of a patient's symptoms and overall health. It involves asking the patient specific questions about various body systems to gather information about any symptoms or concerns they may have. Therefore, ROS is a subjective component of medical assessment and is not related to objective findings or medical decision-making.

Explanation

The correct answer is "Subjective" because ROS stands for Review of Systems, which is a subjective assessment of a patient's symptoms and overall health. It involves asking the patient specific questions about various body systems to gather information about any symptoms or concerns they may have. Therefore, ROS is a subjective component of medical assessment and is not related to objective findings or medical decision-making.

6. We can code acute inpatient condition form PMH if meat is found.

True

False

The statement suggests that we can code an acute inpatient condition form PMH (Past Medical History) if meat is found. However, this is incorrect. PMH refers to a patient's medical history, which includes past diagnoses, treatments, and surgeries. It does not involve coding acute inpatient conditions based on the presence of meat. Therefore, the correct answer is False.

Explanation

The statement suggests that we can code an acute inpatient condition form PMH (Past Medical History) if meat is found. However, this is incorrect. PMH refers to a patient's medical history, which includes past diagnoses, treatments, and surgeries. It does not involve coding acute inpatient conditions based on the presence of meat. Therefore, the correct answer is False.

7. Advair for COPD, in this case COPD can be coded directly from Medication list

True

False

In this case, the statement is suggesting that the code for COPD can be directly obtained from the medication list of a patient who is taking Advair for COPD. Therefore, the answer "True" indicates that this statement is correct.

Explanation

In this case, the statement is suggesting that the code for COPD can be directly obtained from the medication list of a patient who is taking Advair for COPD. Therefore, the answer "True" indicates that this statement is correct.

8. We can not code malignant neoplsam from assessment without further meat.

True

False

The statement suggests that without additional information or context, it is not possible to code malignant neoplasms from an assessment. This implies that coding requires more specific details or meat about the condition in order to accurately assign the appropriate code. Therefore, the answer "True" indicates that the statement is correct and further information is necessary to code malignant neoplasms.

Explanation

The statement suggests that without additional information or context, it is not possible to code malignant neoplasms from an assessment. This implies that coding requires more specific details or meat about the condition in order to accurately assign the appropriate code. Therefore, the answer "True" indicates that the statement is correct and further information is necessary to code malignant neoplasms.

9. Skip the visit if Signature is given by invalid provider.

True

False

If the statement is true, it means that if the signature is given by an invalid provider, it is recommended to skip the visit. This implies that the signature is an important factor in determining the validity or reliability of the provider. By skipping the visit, it ensures that the individual does not receive services from a provider who may not meet the necessary standards or qualifications.

Explanation

If the statement is true, it means that if the signature is given by an invalid provider, it is recommended to skip the visit. This implies that the signature is an important factor in determining the validity or reliability of the provider. By skipping the visit, it ensures that the individual does not receive services from a provider who may not meet the necessary standards or qualifications.

10. Patient came for chest pain, final Diagnosis is probable angina and HTN . And advised to start nitroglycerine. Correct codes ?

401.1

401.9 and 413.9

401.0 and 413.9

None of the above

The correct codes would be 413.9 for probable angina and HTN, but nitroglycerine is not indicated for HTN alone, so none of the options provided are correct.

Explanation

The correct codes would be 413.9 for probable angina and HTN, but nitroglycerine is not indicated for HTN alone, so none of the options provided are correct.