Documentation For Advanced Practice Nurses printable pdf download

Documentation For Advanced Practice Nurses

Documentation for Advanced Practice Nurses

Instructor

Name

Class

Period

Date

Multiple Choice: For each of the following questions, circle the letter of the answer that best answers the

question.

1. A well-documented patient care record demonstrates competent practice to which of the following

regulatory agencies?

A. Medicare

B. Third parties and other stakeholders

C. Board of Nursing

D. All of the Above

2. Which of the following actions is appropriate when working on a patient’s medical record?

A. Alter a medical record

B. Destroy a medical record

C. Remove a medical record

D. None of the above

3. Which of the following is an acceptable guideline to utilize when making a late addition or correction

to a patient’s care record?

A. Erase the error and rewrite the correction

B. Use white-out to remove the error and rewrite the correction

C. Mark with one red line through the item

D. Use permanent marker to completely blot out the error

4. All of the following are required to ensure accurate billing EXCEPT:

A. A description of the patient

B. The actual provider

C. The diagnosis

D. The service or services provided

5. Which of the following actions do not constitute Medicare fraud and abuse?

A. Submitting bills for services not rendered

B. Internally auditing your facility’s documentation to ensure documentation supports the code

billed

C. Unbundle a service

D. Upcode a service

6. Documentation of differential diagnosis in the patient care record allows the APN to:

A. More clearly understand a patient’s condition or circumstance

B. Upcode the service

C. Be familiar with health plan participation contracts

D. Alter the patient’s medical record

Documentation For Advanced Practice Nurses