CHDS Clinical Interpretation and Documentation Integrity Guide Study Guide

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A rehabilitation note describes coughing when drinking water and difficulty swallowing tablets. Another sentence says the patient understands instructions and names objects correctly. Select dysphagia for the swallowing problem without adding a language diagnosis.

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A neurologic report says a patient speaks in long sentences but cannot reliably follow spoken instructions or understand written questions. Recognize that fluent speech remains compatible with aphasia and preserve the documented comprehension deficits.

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An exercise gives potassium as 3.1 mmol/L and a reference interval of 3.5–5.0 mmol/L. Classify the result as low. If the narrative calls it hyperkalemia, flag the conflict between the term and result.

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A draft changes a dictated potassium result from 4.2 to 2.4 mmol/L. Compare the digits carefully and restore the supported value, recognizing that the substitution creates a substantially different electrolyte finding in the record.

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A follow-up note reports an improved glucose reading this morning but an elevated A1c. Retain both results: the current glucose describes that sampling time, while A1c reflects a substantially longer period of glycemic exposure.

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Using exercise intervals of TSH 0.5–4.5 mIU/L and free T4 0.8–1.8 ng/dL, TSH 8.0 with free T4 0.5 supports a primary hypothyroid pattern. TSH 0.05 with free T4 2.4 supports a hyperthyroid pattern. Preserve the clinician's diagnosis and investigation of cause.

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A report groups hemoglobin, hematocrit, MCV, and platelet count under a CBC heading, then unexpectedly inserts HbA1c as another red cell index. Recognize HbA1c as a separate glycemic test and verify the intended organization.

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A laboratory excerpt lists hemoglobin 12.8 g/dL and hematocrit 38%. A draft reverses their labels. Use the measurement types and units to detect the transposition, then verify and restore the supported label-value pairs.

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An exercise reports an MCV of 72 fL with an interval of 80–100 fL. Identify the cells as microcytic by this index, while leaving the cause unspecified unless the report provides a supported diagnosis.

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An exercise gives ALT 96 U/L with an upper limit of 40, bilirubin 2.4 mg/dL with an upper limit of 1.2, and albumin 2.8 g/dL with an interval of 3.5–5.0. Identify elevated ALT, elevated bilirubin, and reduced albumin as a pattern supporting liver-disease evaluation.

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Using exercise intervals of hemoglobin 12–16 g/dL, MCV 80–100 fL, and ferritin 20–200 micrograms/L, results of 9.8 g/dL, 70 fL, and 6 micrograms/L show anemia, microcytosis, and depleted iron stores. Preserve the clinician's evaluation of the source of iron loss or inadequate supply.

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A postmenopausal patient's hip DXA T-score is −2.7. Decode this as density 2.7 standard deviations below the young-adult reference and classify it in the osteoporosis range. A T-score of −1.8 instead falls in the low-bone-mass range.

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A chemistry report includes creatinine and an automatically calculated eGFR, without an administered filtration marker. Describe eGFR as an estimate of kidney filtration rather than stating that the laboratory directly measured glomerular filtration during the visit.

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An eGFR of 48 during an acute illness, followed by recovery to 85, does not establish chronicity. Estimates of 52 and 50 documented four months apart, with evidence that the reduction persisted, support the duration and filtration criteria. Persistent urine ACR of 30 mg/g can meet the albuminuria threshold even when eGFR is above 60.

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A draft describes an MRI as a rotating x-ray examination. Recognize that description as inconsistent with magnetic resonance technology and verify the intended modality before allowing the report to combine incompatible imaging mechanisms.

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A screening note records an implanted device but omits its model and MRI conditions. Identify the missing device-specific information rather than rewriting the note to say MRI is safe simply because it does not use x-rays.

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A draft labels an examination as contrast-enhanced MRI but names an iodine-based intravenous agent. Check the original study information because the usual MRI association is gadolinium-based contrast; do not independently change either the study or agent.

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An abdominal imaging note states oral contrast was given and explicitly says no intravenous contrast was administered. Preserve both details; changing the report to intravenous contrast would misrepresent how the bowel and other structures were evaluated.

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A dermatology note describes a 4-mm lesion that has developed an irregular border and uneven pigmentation over two months. Preserve the changing features and planned evaluation; its diameter alone does not justify calling it benign.

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An imaging excerpt describes fluid surrounding the lower portion of the left lung within the pleural space. Select pleural effusion and retain left-sided location, without changing the finding to air in that space.

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A postoperative radiology note states that air is present between the right lung and chest wall, with partial lung collapse. Recognize pneumothorax as the matching term rather than replacing it with pleural effusion.

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A clinician explicitly diagnoses pleurisy after describing sharp pain with inspiration. Preserve the inflammatory term. If imaging also reports an effusion, retain it as an additional finding rather than assuming the two words mean the same condition.

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A narrative places the mitral valve between the right atrium and ventricle and calls oxygenated pulmonary return an artery. For ordinary anatomy, identify tricuspid valve and pulmonary veins as the corresponding structures, then verify the source before correction.

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An exercise reports end-diastolic volume 150 mL and end-systolic volume 105 mL. Stroke volume is 45 mL, and EF is 45 ÷ 150 × 100 = 30%. A draft reporting 70% conflicts with these supplied volumes.

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An ophthalmology note records right-eye acuity 20/20 and left-eye acuity 20/40 with correction. Preserve the eye and correction status; the left-eye result shows poorer measured distance acuity than the right-eye result under those testing conditions.

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A labor note records dilation 6 cm and station −1. Retain two separate findings: cervical opening is 6 cm, while the presenting part remains above the ischial spines. A change from −1 to +1 indicates descent across that reference level.

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A respiratory note documents albuterol inhalation for wheezing but a draft calls it an antibiotic. Correct the drug-category description to bronchodilator, without adding a bacterial diagnosis or supplying an unrecorded dosing schedule.

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A treatment record describes liquid albuterol placed into a nebulizer cup and inhaled through a mask. Keep nebulized inhalation wording rather than substituting metered-dose inhaler, which describes a different delivery setup.

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At one minute, documented component scores of 1, 2, 1, 1, and 2 total 7. A five-minute total of 9 should be recorded separately as improvement over time, rather than combined into a score of 16 or expressed as 7/9 points on one assessment.

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A draft says the gallbladder manufactures bile and the liver stores it. Reverse that functional assignment to match the supported anatomy, then retain the report's separate description of where the gallstones are located.

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An operative report describes camera-guided dissection through small incisions followed by a larger incision to complete gallbladder removal. Summarize cholecystectomy converted from laparoscopic to open, retaining both the procedure and conversion.

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An operative excerpt describes a longer scope advanced through the bladder into a ureter to retrieve a stone. Identify ureteroscopy. A scope used only to inspect the bladder lining supports cystoscopy instead.

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A procedure report describes oral endoscope passage to the duodenum, duct cannulation, contrast injection, fluoroscopy, and extraction of a common bile duct stone. These combined cues identify ERCP without establishing that the gallbladder was removed.

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A knee report describes an arthroscope through a portal and removal of the torn portion of a meniscus with instruments through another portal. Preserve arthroscopic partial meniscal resection rather than changing removal to repair.

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An oncology excerpt records N0 M0. Decode these as no regional lymph node involvement and no distant metastasis within the classification. Do not infer the primary tumor category or overall stage from those two components.

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A pathology report using that scheme records grade 3, while staging shows localized disease. Interpret grade 3 as poorly differentiated microscopic appearance within that system; retain localized extent without rewriting the case as stage III.

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An editor sees a prior hospitalization's oxygen requirement beside today's outpatient note. Keep its historical date and context rather than importing it into the current examination as though oxygen support were confirmed at this visit.

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A receiving system displays an outside test name but omits its unit and collection date. Identify an information-usability problem even though the file arrived successfully; the missing context limits interpretation of the transferred result.

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Two records share the same first and last name but have different birth dates and addresses. Pause attachment of a dictated report and use the identity-resolution process rather than selecting the first name match returned.

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A note contains a surgical history that conflicts with the chart and a different birth date in its imported header. Investigate patient association first rather than deleting the unfamiliar surgery to make the note fit.

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Two laboratories use different local names for an equivalent observation. Their correctly mapped LOINC identifier can support recognizing the shared measurement, but an editor must still retain each reported value, unit, date, and applicable reference interval.

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An EHR displays a synonym after a terminology update while retaining the same underlying SNOMED CT concept. Check the concept identity before treating the wording change as a new diagnosis or a newly added clinical finding.

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A project needs a common identifier for the laboratory observation performed across several sites, then a clinical concept for a documented disorder. Select LOINC for the observation task and an appropriate clinical terminology for the disorder.

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A measurement worksheet asks for 0.6 mg expressed in micrograms. Multiply by 1,000 to obtain 600 micrograms, then confirm that converting back by dividing by 1,000 returns the original 0.6 mg.

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An exercise asks for 0.075 L in milliliters. Calculate 75 mL and verify by dividing 75 by 1,000. Do not add a rate such as mL/hour because the original quantity supplies no time interval.

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A technical measurement table changes a lowercase prefix to uppercase during formatting. Check the SI meaning before accepting the edit, because a typographic-looking change can turn a subunit into a multiple of the base unit.

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The dictated statement is that there is no pleural effusion, but the draft states that there is pleural effusion. Restore the negation and confirm that the remaining sentence still refers to the same finding and side.

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A draft accurately captures 0.8 but changes the dictated mass unit from mg to micrograms. Identify the unit substitution as a quantity-changing error, then restore the supported unit rather than changing the number to fit the draft.

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The dictated impression identifies a right pleural effusion, while the recognized draft says left pleural effusion. Correct the supported side and review other side references without automatically changing unrelated findings elsewhere in the report.

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Original draft: 'A d-dimer was ordered at the follow-up visit.' Required correction: 'A D-dimer was ordered at the follow-up visit.' Capitalize D in the test name. Rewriting follow-up as followup is unnecessary for this exercise because the published clarification accepts the hyphenated adjective.

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A template inserts a normal respiratory examination before the clinician records wheezing. Identify the prefilled paragraph as reusable content requiring reconciliation, rather than treating the template's normal wording as stronger evidence than the encounter findings.

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A current examination describes difficulty naming objects, but an inserted normal paragraph states that language testing is entirely intact. Flag the conflicting language findings and obtain reconciliation rather than deleting the abnormal observation on your own.

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A consultation incorporates a paragraph from an earlier specialist note. Keep its source and date identifiable and verify its relevance, rather than presenting the paragraph as a new observation made by the consulting clinician today.

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Yesterday's note says a culture is pending, but today's results are available. A copied progress note retains pending wording. Identify the outdated status and obtain an accurate current statement rather than carrying the unresolved plan forward.

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A pasted paragraph contains another patient's name and an unfamiliar medication list. Do not replace only the name. Stop reuse, verify the intended patient's information, and address the misplaced content through the established correction workflow.

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A dictated assessment calls potassium high, while the supplied value is below its stated interval. Send a focused query containing the term, result, unit, and interval rather than choosing a new value or diagnosis independently.

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An editor identifies conflicting operative side statements and sends them for clarification. After the clinician supplies the correct side, follow the record's correction and authentication process rather than assuming the editor's completed text alone resolves author responsibility.

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A patient states a gender identity that differs from sex assigned at birth. Record the stated identity in the appropriate location and retain separately relevant clinical information without changing either attribute to force them into one category.

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A note describes a patient's clothing and then assumes a sexual orientation from that observation. Remove the unsupported inference through the appropriate review process, retaining only relevant, accurately documented information rather than treating presentation as proof of attraction.

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A patient requests different pronouns from those in an old note. Update the relevant communication information through the established workflow, verify patient identity with appropriate identifiers, and review copied prose rather than carrying the old wording forward automatically.