Question

about universal fields on electronic progress notes:

disregard fields that do not appear to apply.
every field must be completed.
enter dk if you dont know the answer.
leave them blank for the qmhp to complete.

Explanation:

Analyze documentation requirements for electronic progress notes

Under Medicaid documentation standards and KDADS regulations, "universal fields" on electronic progress notes are mandatory elements that establish the validity, compliance, and medical necessity of the service provided.

Evaluate the options based on compliance standards

• Leaving fields blank, disregarding them, or entering "DK" (Don't Know) violates compliance and audit guidelines, which require complete records to prevent billing fraud and ensure quality of care.
• Therefore, every universal field on an electronic progress note must be fully completed to ensure the documentation is legally and clinically valid.

Answer:

• Disregard fields that do not appear to apply.
• Every field must be completed. (Correct answer)
• Enter DK if you don't know the answer.
• Leave them blank for the QMHP to complete.