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CDEO practice questions

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Question 1Core documentation review

Which element of the medical record captures the reason for the visit as described in the patient's own words?

  1. Chief complaint Correct answer.
  2. Family history
  3. Review of systems
  4. Past medical history

Explanation

The chief complaint is a brief statement, usually in the patient's own words, describing the symptom or problem that prompted the encounter. It anchors the history and helps establish why the service was medically necessary.

Question 2Core documentation review

An extended history of present illness requires documentation of at least how many HPI elements?

  1. Two
  2. Eight
  3. Four Correct answer.
  4. Three

Explanation

The eight HPI elements are location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms. A brief HPI documents one to three of these, while an extended HPI requires at least four.

Question 3Core documentation review

Documentation of a patient's tobacco use, alcohol use, and occupational exposures belongs to which history component?

  1. Family history
  2. Social history Correct answer.
  3. History of present illness
  4. Review of systems

Explanation

Social history captures lifestyle and environmental factors such as tobacco, alcohol, drug use, occupation, and living situation. These factors are recorded separately from the symptom narrative and from relatives' conditions.

Question 4Core documentation review

Which of the following is an acceptable way to authenticate an entry in the electronic medical record?

  1. A signature stamp applied by the front office staff
  2. A coworker entering the provider's name in the author field
  3. Initials typed at the end of the note
  4. A unique credentialed electronic signature Correct answer.

Explanation

Authentication must verify the identity of the author and be traceable. In an EHR, a unique user credential or electronic signature tied to an audit trail satisfies this requirement; stamps and signing for another provider do not.

Question 5Core documentation review

The SOAP note format organizes encounter documentation into which four sections?

  1. Subjective, Observation, Analysis, Procedure
  2. Summary, Objective, Assessment, Prognosis
  3. Symptoms, Observation, Action, Progress
  4. Subjective, Objective, Assessment, Plan Correct answer.

Explanation

SOAP stands for Subjective, Objective, Assessment, and Plan. Subjective covers patient-reported information, objective covers measurable findings, assessment states the clinical impression, and plan records the management course.

Question 6Core documentation review

Which of the following is an objective finding in the medical record?

  1. The patient's description of chest pain
  2. The patient's report of nausea
  3. The patient's statement that a parent had diabetes
  4. A recorded blood pressure of 158/94 Correct answer.

Explanation

Objective findings are observable or measurable data obtained by the clinician, such as vital signs and examination results. Subjective information consists of what the patient reports.

Question 7Core documentation review

How should a late entry be added to a paper medical record?

  1. Write it over the original entry in darker ink
  2. Backdate the entry to the original date of service
  3. Add it on a new page without referencing the original entry
  4. Enter it with the current date, time, and a note explaining the delay Correct answer.

Explanation

A late entry is written as soon as the omission is discovered and bears the date and time it is actually recorded, along with a brief reason for the delay. The original documentation is never altered or backdated.

Question 8Core documentation review

A patient declines a recommended stress test. What should the documentation reflect?

  1. Nothing, because the test was never performed
  2. The word "refused" entered in the plan section
  3. A copy of the practice's written scheduling policy for the test
  4. The risks and benefits explained and the patient's reason Correct answer.

Explanation

When a patient declines recommended care, the record should show that risks and benefits were explained, that the patient understood them, and the patient's stated reason. This documents an informed refusal and supports the decision making.

Question 9Core documentation review

Under the standard E/M documentation guidelines, a complete review of systems requires documentation of at least how many organ systems?

  1. Two
  2. Ten Correct answer.
  3. Fourteen
  4. Five

Explanation

A complete review of systems documents at least 10 organ systems, with positive responses and pertinent negatives noted. A problem-pertinent review covers one system, and an extended review covers two to nine.

Question 10Core documentation review

Which level of past, family, and social history is required to support a comprehensive history for a new patient?

  1. An extended HPI in place of PFSH
  2. Pertinent PFSH only
  3. Complete PFSH Correct answer.
  4. No PFSH is required

Explanation

A comprehensive history requires a complete PFSH, which for a new patient means all three areas are documented. For an established patient, a complete PFSH requires two of the three areas.

Question 11Core documentation review

Which is the greatest documentation risk of routinely using copy-and-paste in the electronic record?

  1. The audit trail is permanently deleted
  2. Outdated or inaccurate information carries forward Correct answer.
  3. The note becomes longer than payers allow
  4. The provider's electronic signature is invalidated

Explanation

Copying forward prior text can carry stale findings, resolved problems, or another patient's details into the current note, making the record inaccurate. The documentation must reflect the patient's condition on the date of service.

Question 12Core documentation review

A covering provider accepts a telephone order from the treating physician. What must the documentation of that order include?

  1. The ordering physician's name, date, and time received Correct answer.
  2. The ordering physician's national provider identifier and tax number
  3. The patient's insurance information
  4. Only the order itself and the date

Explanation

Telephone and verbal orders are documented with the order, the name of the ordering provider, and the date and time it was received, signed by the person taking the order. Organization policy then governs countersignature.

Question 13Core documentation review

Under the current E/M guidelines, which three elements make up medical decision making?

  1. History, examination, and time
  2. Diagnoses, procedures, and referrals
  3. Chief complaint, review of systems, and plan
  4. Problems addressed, data reviewed, risk of complications Correct answer.

Explanation

Medical decision making is composed of the number and complexity of problems addressed, the amount and complexity of data reviewed, and the risk of complications, morbidity, or mortality. Two of the three must be met or exceeded for a given level.

Question 14Core documentation review

A provider reports an office visit based on time. Which time is counted?

  1. The length of the scheduled appointment slot
  2. The time clinical staff spent on patient education
  3. The time the note was finalized in the electronic record
  4. Provider time on the date of the encounter Correct answer.

Explanation

Time-based reporting uses the total time on the date of the encounter that the billing practitioner personally spends on the visit, including both face-to-face and non-face-to-face activities such as record review and ordering tests.

Question 15Core documentation review

When a resident documents an encounter and the teaching physician performs the key portions, what must the teaching physician's note show?

  1. That the teaching physician personally performed the key portions Correct answer.
  2. That the resident's documentation alone supports the service
  3. Only an attending signature on the resident's note
  4. A statement that the resident was supervised during the entire prior year

Explanation

Payment for teaching physician services requires the teaching physician to document personal involvement in the key portions of the service, either in his or her own note or by referencing the resident's note in a way that makes the combined record clear.

Question 16Core documentation review

What is the primary purpose of the problem list in the medical record?

  1. To list only those conditions that have resolved
  2. To summarize active conditions that guide care Correct answer.
  3. To record the charges for each visit in the record
  4. To replace the assessment and plan for the encounter

Explanation

The problem list is a running summary of the patient's active and clinically significant conditions. It supports continuity of care and helps demonstrate the context for the services ordered and performed.

Question 17Core documentation review

A provider orders an MRI of the lumbar spine. Which documentation best supports the medical necessity of the order?

  1. A note that the practice owns an MRI scanner
  2. A copy of the patient's insurance card
  3. A statement that the patient requested the imaging study
  4. The symptoms and failed conservative treatment prompting it Correct answer.

Explanation

Medical necessity is supported by the clinical findings that led to the order, such as the nature and duration of symptoms and the failure of prior treatment. This ties the service to a documented clinical rationale.

Question 18Core documentation review

What is the correct way to correct a handwritten error in a paper chart?

  1. Cover the error with correction fluid
  2. Draw a single line through it, add initials, date, and the correction Correct answer.
  3. Erase the error and rewrite the entry
  4. Rewrite the entire page and discard the original

Explanation

A correction leaves the original entry readable, with a single line drawn through it, plus the initials and date of the person making the change and the corrected information. This preserves the integrity of the record.

Question 19Core documentation review

Which of the following must appear in a hospital discharge summary?

  1. The names of every hospital employee who provided care
  2. Admission reason, findings, and discharge instructions Correct answer.
  3. A copy of the signed admission consent form
  4. The patient's insurance billing history

Explanation

A discharge summary communicates the reason for admission, significant findings and procedures, the hospital course, the patient's condition at discharge, and follow-up instructions. This content supports continuity of care after discharge.

Question 20Core documentation review

A provider edits a signed note in the electronic record to add an examination finding. What must the amendment preserve?

  1. The prior version plus the date, author, and reason Correct answer.
  2. A verbal confirmation obtained from the patient
  3. The original note's signature block left unchanged
  4. Only the amended version of the note

Explanation

An amendment must retain the original content, identify who made the change and when, and state why the change was made. The record therefore shows both what was originally documented and how it was modified.

Question 21Core documentation review

Under the 1995 E/M documentation guidelines, a detailed examination requires documentation of how many body areas or organ systems?

  1. Two to four
  2. At least eight
  3. Exactly one
  4. Five to seven Correct answer.

Explanation

The 1995 guidelines grade the examination by the number of body areas and organ systems examined: problem focused is one, expanded problem focused is two to four, detailed is five to seven, and comprehensive is eight or more.

Question 22Core documentation review

Under the current E/M guidelines, which documentation supports the data element at a moderate level of medical decision making?

  1. Review of three unique tests or two tests with a historian Correct answer.
  2. Review of no external records or test results
  3. Ordering a test without reviewing the result
  4. Review of the results of one unique test ordered by the provider

Explanation

The data element reaches the moderate level when the results of three unique tests are reviewed, or when two unique tests are reviewed and at least one involves an external note or an independent historian. Lower amounts of data reviewed support only lower levels.

Question 23Core documentation review

A note records 40 total minutes for an established patient visit, including 15 minutes of medication counseling performed by a nurse. How should time be applied?

  1. Count only the time the provider personally spent Correct answer.
  2. Exclude any time the provider spent on the computer
  3. All 40 minutes count as provider time
  4. The total is split between the provider and the nurse

Explanation

Only the time the billing practitioner personally spends on the date of the encounter counts toward time-based reporting. Ancillary staff time, regardless of the activity performed, is not included.

Question 24Core documentation review

An auditor finds an assessment listing four chronic conditions, but the plan addresses only one and the note reports no change in the others. What is the main documentation concern?

  1. The provider did not record total time on the date of service
  2. The note does not include a review of systems
  3. The examination is not documented by body system
  4. The assessment and plan are inconsistent Correct answer.

Explanation

The number and complexity of problems addressed must be supported by both the assessment and the plan. Listing conditions that are not evaluated or managed inflates the apparent complexity and undermines the reported level of service.

Question 25Core documentation review

Under the current E/M guidelines, how do history and examination affect the level of an office visit reported on medical decision making?

  1. They must satisfy the 1997 body-system counts for the level
  2. Documented as appropriate, but they do not set the level Correct answer.
  3. They are required only for new patient encounters
  4. They replace medical decision making when the note is detailed

Explanation

History and examination should still be documented as medically appropriate for the encounter, but they no longer determine the visit level when the service is reported on medical decision making. Medical decision making or total time selects the level.

Question 26Core documentation review

Which abbreviation is on The Joint Commission's official 'Do Not Use' list?

  1. mg
  2. po
  3. U Correct answer.
  4. mL

Explanation

The letter U can be mistaken for the number 0, the number 4, or the abbreviation cc. The safe alternative is to write 'unit' in full.

Question 27Core documentation review

Which element must be present on every entry in the medical record?

  1. The date and author of the entry Correct answer.
  2. A procedure code
  3. A diagnosis code
  4. The patient's insurance number

Explanation

Every medical record entry must identify when the entry was made and who made it. This supports accountability and continuity of care.

Question 28Core documentation review

What is the chief complaint?

  1. The objective findings from the physical examination
  2. A list of the patient's current medications
  3. The provider's assessment of the patient's condition
  4. The patient's own words describing the reason for the visit Correct answer.

Explanation

The chief complaint is a brief statement, preferably in the patient's own words, that identifies the reason for the encounter. It is not the provider's diagnosis or assessment.

Question 29Core documentation review

Which item is part of the past medical history?

  1. The patient's prior surgeries Correct answer.
  2. The patient's family illnesses
  3. The patient's review of symptoms
  4. The patient's occupation

Explanation

Past medical history includes prior illnesses, surgeries, hospitalizations, and similar health events. Occupation and family illnesses are captured in other history sections.

Question 30Core documentation review

Which item is part of the social history?

  1. Review of body systems
  2. Childhood immunizations
  3. Tobacco use Correct answer.
  4. Current prescription doses

Explanation

Social history documents lifestyle and environmental factors such as tobacco, alcohol, occupation, and living situation. Immunizations and medication doses belong in other sections.

Question 31Core documentation review

What must be documented with an allergy entry in the medical record?

  1. The patient's insurance authorization
  2. The date the allergy was first coded
  3. The pharmacy phone number
  4. The substance and the reaction Correct answer.

Explanation

Allergy documentation should identify the substance and the reaction the patient experienced. This helps clinicians avoid unsafe orders and recognize prior reactions.

Question 32Core documentation review

What is the primary purpose of authenticating a medical record entry?

  1. To assign the correct billing level
  2. To replace the need for a problem list
  3. To identify the author and the date of the entry Correct answer.
  4. To satisfy the patient's request for a copy

Explanation

Authentication verifies who created or approved the entry and when it was documented. It supports accountability and the integrity of the record.

Question 33Core documentation review

Which is required for a valid provider signature in the medical record?

  1. A stamped signature
  2. A legible name and professional credentials Correct answer.
  3. A co-signature from the office manager
  4. An initials-only entry

Explanation

A valid signature must identify the provider clearly, including name and professional credentials, and should be dated. Stamped or initials-only entries generally do not meet authentication standards.

Question 34Core documentation review

What does an electronic health record audit trail document?

  1. Who accessed or changed an entry, when, and what action was taken Correct answer.
  2. The patient's insurance eligibility
  3. The billing code assigned to the visit
  4. Only the final version of the note

Explanation

An audit trail records access and changes to the record, including the user, date and time, and action performed. This supports record integrity and investigation of documentation concerns.

Question 35Core documentation review

A patient is unable to provide a history because of confusion. What should the provider document?

  1. A statement that the patient is noncompliant
  2. No history was obtained
  3. The reason history is limited and the source of the history used Correct answer.
  4. Only the patient's vital signs

Explanation

When a patient cannot provide a history, the record should explain why and identify the source used, such as a family member or prior records. This preserves the clinical basis for decisions.

Question 36Core documentation review

What is the purpose of a provider query in documentation review?

  1. To clarify ambiguous or conflicting documentation Correct answer.
  2. To schedule a follow-up appointment
  3. To request payment from the insurer
  4. To replace the physician's signature

Explanation

A query asks the provider to clarify unclear, incomplete, or conflicting documentation so the record accurately reflects the encounter. It should not lead the provider to a predetermined answer.

Question 37Core documentation review

What must be documented to support informed consent for a procedure?

  1. Only the patient's signature
  2. The risks, benefits, alternatives, and patient's questions Correct answer.
  3. The patient's insurance authorization
  4. The procedure code and fee

Explanation

Informed consent documentation should reflect the discussion of risks, benefits, and alternatives, as well as the patient's questions and decision. A signature alone does not show that the discussion occurred.

Question 38Core documentation review

Which element is required in a hospital discharge summary?

  1. The hospital course and follow-up plan Correct answer.
  2. The nurse's home phone number
  3. The names of all visitors
  4. The patient's home address

Explanation

A discharge summary communicates the hospital course, significant findings, discharge medications, and follow-up plan. These elements support continuity of care after discharge.

Question 39Core documentation review

What is medication reconciliation?

  1. Ordering a new medication without review
  2. Counting the number of pills in a bottle
  3. Documenting only the medication name
  4. Comparing the patient's current medication list with the new list and resolving discrepancies Correct answer.

Explanation

Medication reconciliation is the process of comparing the patient's current medications with a new list and resolving any discrepancies. It helps prevent omissions, duplications, and dosing errors.

Question 40Core documentation review

A provider gives a verbal order for a medication. What must the documentation of that order include?

  1. The patient's insurance approval
  2. The order, the reading back, and the prescribing provider Correct answer.
  3. The pharmacy's stock number
  4. Only the medication name

Explanation

A verbal order should be documented with the order itself, confirmation through read-back, and identification of the ordering provider. This reduces medication errors and supports authentication.

Question 41Core documentation review

What is a split/shared E/M visit?

  1. A visit billed by the front desk and the nurse
  2. A visit documented only by the patient
  3. A visit split between two different patients
  4. A visit in which a physician and an NPP each perform part of the encounter and combine their work Correct answer.

Explanation

A split/shared visit occurs when a physician and a nonphysician practitioner each perform part of the same encounter and their work is combined for billing. Documentation must identify each contributor's work.

Question 42Core documentation review

What is required in a consultation note?

  1. The reason for the request and the consultant's recommendations Correct answer.
  2. The patient's billing history
  3. Only the consultant's signature
  4. The primary care provider's schedule

Explanation

A consultation note should document why the consultation was requested, the consultant's findings, and recommendations. This closes the loop for the requesting provider.

Question 43Core documentation review

In an electronic health record, how should an error in a signed note be corrected?

  1. Add an amendment that preserves the original and identifies the correction Correct answer.
  2. Delete the original note and write a new one
  3. Change the original note without documentation
  4. Ask the billing department to edit the note

Explanation

A signed note should be corrected through an amendment that retains the original content and clearly identifies the change, author, and date. Deleting or silently editing the original undermines record integrity.

Question 44Core documentation review

A patient does not attend a scheduled appointment. What should the documentation include?

  1. The provider's opinion of the patient
  2. A diagnosis code for noncompliance
  3. A note that the patient is discharged
  4. The missed appointment and attempts to contact the patient Correct answer.

Explanation

Documentation of a missed appointment should record that the patient did not attend and any attempts to contact or reschedule the patient. This supports continuity and follow-up.

Question 45Core documentation review

What must a late entry in a medical record include in addition to the current date?

  1. The name of the insurer
  2. The billing code
  3. The date of the original service and the reason for the delay Correct answer.
  4. The patient's signature

Explanation

A late entry should identify the date of the actual service and explain why the entry is being made later. The current date shows when the late entry was created.

Question 46Core documentation review

What does the 'minimum necessary' principle mean for documentation?

  1. Omit all sensitive information
  2. Document only the information needed for the patient's care, payment, or operations Correct answer.
  3. Document every detail of the patient's life
  4. Use the fewest words possible in every note

Explanation

The minimum necessary principle limits protected health information to what is reasonably needed for the intended purpose. It does not require omitting clinically relevant details or using artificially brief notes.

Question 47Core documentation review

What is a pertinent negative in documentation?

  1. A normal finding unrelated to the problem
  2. A negative laboratory result that is not reviewed
  3. A patient's refusal of treatment
  4. An absence of a symptom that is relevant to the patient's problem Correct answer.

Explanation

A pertinent negative is the documented absence of a symptom or finding that is relevant to the patient's presenting problem. It helps support clinical reasoning and the assessment.

Question 48Core documentation review

What is the purpose of documenting a patient's decision-making capacity?

  1. To determine insurance coverage
  2. To assign the E/M level
  3. To replace informed consent
  4. To show the patient can understand and make healthcare decisions Correct answer.

Explanation

Documenting decision-making capacity shows whether the patient can understand information and make healthcare decisions. It supports the validity of consent and treatment planning.

Question 49Core documentation review

What must be documented when a diagnostic test is ordered and interpreted by an outside provider?

  1. The patient's insurance approval
  2. The interpretation and the source of the interpretation Correct answer.
  3. The test name only
  4. Only the order date

Explanation

When an outside provider interprets a diagnostic test, the record should include the interpretation and identify its source. This supports clinical decision-making and continuity.

Question 50Core documentation review

Which of the following is required for documentation of a telephone encounter?

  1. The patient's billing code
  2. The phone number of the pharmacy
  3. Only the provider's signature
  4. The date, time, and substance of the call and who was contacted Correct answer.

Explanation

A telephone encounter should document when the call occurred, what was discussed, and who participated. This creates a clear record of the communication and any decisions made.