Admission Note: Post Test – WipeFoundation Education

What are the main components of the initial note for Evaluation & Management (E/M) billing to add the word “admission": What are the main components of the initial admission note for…*

	Not Important	Slightly Important	Important	Very Important	Extremely Important
How important is accurate and comprehensive documentation to you currently?
How important is it to you to have education on proper documentation?

Attitude Questions*

	Not at all confident	Not confident	Somewhat confident	Very confident	Extremely confident
How confident are you about correctly documenting a comprehensive History including CC, HPI, ROS, and PFSH?
How confident are you about correctly documenting a comprehensive physical examination?
How confident are you about correctly documenting an A&P to receive full credits for reviewing data and complexity of Medical Decision Making?
How confident do you feel about judging the correct E/M billing level-of-care for an H&P?

Attitude Questions*
Strongly disagree Disagree Neutral Agree Strongly agree
Assess this statement: Most physicians feel like documentation is a burden.
Assess this statement: I personally feel like documentation is a burden.
What are the main components of the initial note for Evaluation & Management (E/M) billing?*
- History, exam, and counseling & education of patient
- History, exam, and complexity of medical decision making
- Exam, laboratory studies, and coordination of care
- Exam, complexity of medical decision making, counseling & education of patient
- I’m not sure
Which of the following could be billed as a comprehensive history for an inpatient admission note?*
- CC, HPI (with 3 elements), ROS (with 8 elements), PMH, PSH, FH, Social history
- CC, HPI (with 4 elements), ROS (with 10 elements), PMH, FH, Social history
- CC, HPI (with 5 elements), ROS (with 12 elements), PMH, Social history
- CC, HPI (with 6 elements), ROS (with 12 elements), PMH, PSH, Social history
- I’m not sure
What is the minimum number of systems pertaining to a ROS needed in the highest level-of-care history (i.e., HPI and ROS sections) for an admission note?*
- 8
- 10
- 11
- 12
- I’m not sure
What is the minimum number of elements of a problem (e.g. location, timing, duration, context, moderating factors, associated signs & symptoms, quality, severity) in an HPI needed for the highest and second highest level-of-care History?*
- 3
- 4
- 5
- 6
- I’m not sure
Is documentation of a Family History always required for a complete Family History section?*
- Yes
- No
- I’m not sure
How many different organ systems are needed and how many exam findings must be documented for the highest level-of-care Exam?*
- 2 exam findings in 6 organ systems
- 1 exam finding in 7 organ systems
- 1 exam finding in 8 organ systems
- 2 exam findings in 9 organ systems
- I’m not sure
What is the INCORRECT way to document HTN as an active issue in the A&P section?*
- HTN with hypotension
- Chronic HTN with hypotension
- Essential HTN with hypotension
- History of HTN with hypotension
- I’m not sure
One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment. What Is the level of complexity for Medical Decision Making for an admission note?*
- Moderate
- High
- I’m not sure
Drug therapy requiring monitoring for toxicity. What Is the level of complexity for Medical Decision Making for an admission note?*
- Moderate
- High
- I’m not sure
Parenteral controlled substances (e.g. iv Dilaudid). What Is the level of complexity for Medical Decision Making for an admission note?*
- Moderate
- High
- I’m not sure
Two or more stable chronic illnesses. What Is the level of complexity for Medical Decision Making for an admission note?*
- Moderate
- High
- I’m not sure
Undiagnosed new problem with uncertain diagnosis (e.g. breast mass, lung mass, etc). What Is the level of complexity for Medical Decision Making for an admission note?*
- Moderate
- High
- I’m not sure

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
Assess this statement: Most physicians feel like documentation is a burden.
Assess this statement: I personally feel like documentation is a burden.