Module 5 CDI Assessment

When 'vital signs' are not recorded during a patient visit, what is the corrective action?

If critical test results lack documented read-back verification, which protocol should be followed?

In the process of clinical documentation, which action is most appropriate if a plan of care is not documented?

If a patient requires a referral to a physical therapist, what should be the primary focus of documentation?

What immediate step should be taken if documentation of comprehensive history and physical examination (H&P) is absent during a patient's initial visit?

When a patient requires assessment for the risk of falls, what is the MOST crucial element to document?

Why is documenting social screening essential for clinical assessment?

In interdisciplinary consultations, what specific detail is most important to include in the documentation?

If a nursing survey is not included, what should be the immediate measure taken?

What information should be documented when a patient is referred to a nutritionist?

What are the key components of medical documentation standards?

Which of the following are key components of medical documentation standards?

What are the main components of medical documentation standards?

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PC.3.2 requires that complete blood counts be taken in each visit.

PC.3.2 mandates a specialized cardiac assessment during the first visit.

PC.3.3 dictates that educational screening be documented.

PC.3.3 requires 'Genetic screening' to be documented.

Under PC.3.3 'Ocular' screening should be documented.

PC.3.3 includes documenting 'Social screening'.

PC.3.3 involves documenting the risk of injury.

According to PC.3.4 a symptom assessment should be completed.

According to PC.3.4 the patient has to be referred to a podiatrist.

According to PC.3.4 the patient must be referred to a physical therapist.

PC.5.3 mandates that read back is documented exclusively for routine blood tests.

PC.6.1 requires that scope of care be documented.

According to PC.6.3 the care should be reviewed monthly.

PC.7.1 mandates a summary of financial data of other services.

A failure to document the treatment plan requires notifying the nurse.

Match the following clinical documentation elements (left) with the most relevant standard, PC.3.2, PC.3.3, PC.3.4, PC.5.3 (right) from the provided document:

Match the following clinical documentation elements (left) with the most relevant standard, PC.6.1, PC.6.3, PC.7.1, PC.3.2 (right) from the provided document:

Match each clinical documentation audit area with the action required based on the 'Analysis of Data' section:

Match the stage of clinical documentation improvement strategies to the relevant step:

Match the documentation standard to the element:

Match the element from the documentation:

Match the documentation process:

Match the description of the metric:

Match the role to the task:

Match the documentation improvements to the outcome:

Match the reasons why accurate standards for documentation are important:

Match the standard of documenting H&P with the time frame:

Match the reason for a audit with what you want to achieve:

Match the following documentation methods:

Match these staff actions to improve data:

Match the process steps:

Match the standard to the result:

Match the data to the decision:

Match reason and result for clinical data.