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MOT 124

CH 4-5-7

Why is a patient consent form important? It permits physicians and other hospital staff to provide general care.
An unexpected visit to the emergency room would cause the patient to be admitted as__________? An emergency admission
What is a direct admission? When a patient has an appointment for a procedure at the hospital.
Who qualifies as a transfer patient? A patient who comes from another facility or hospital.
When are newborns considered to be admitted into the hospital? At the time of birth or soon after.
All instances of admission require a doctor's order except? Newborns
Elements of Data Quality include: Accuracy, Validity, Timeliness, and Completeness
List the three types of controls used over the collection and recording of data. Preventative, detective, corrective
What is the element of quantitative analysis whose common deficiency is a missing item? Existence
Data are correct refers to what element of data quality? Accuracy
If a patient's record is missing the reason for a consultation, what element of quantitative analysis would this fall under? Completeness
What control helps to eleminate errors before they occur? Preventative controls
HIM professionals must do what to ensure that good data have been collected? They must develop and implement controls
Data fall within predetermined values or parameters refers to what element of data quality? Validity
What issues can be attributed to record keeping in a rehabilitation facility? There is little time for the therapist to document between patients.
Give examples of different types of therapies found in a rehabilitation facility. Physical, Occupational, Speech, Cognitive remediation.
The best example of a preventive control is what? A computer validity check
In a paper-based system, what helps to ensure that the data collection is completed? Well designed pre-printed forms
This setting only provides palliative care to its patients. Hospice
Data are recorded within a predetermined period refers to what element of data quality? Timeliness
What is the element of quantitative analysis refers to the signature of the author of a report? Authentication
The process of completing missing elements in a record is called what? Deficiency system
Computer-based validity check data entry, examination of patient identification before medications are administered are examples of what type of control? Preventive
Correction of errors that have been discovered including investigation of he source of the error refers to what type of control? Corrective
A number of activities in which specific data are located in the record and transferred to another document is called what? Abstracting
Quantitative analysis (error or exception report) are examples of what type of control? Detective
What is the function of retrieving the health record and providing it, or parts of it, to individuals who need it called? Release of information or correspondence
Data exist in their entirety refer to what element of data quality? Completeness
What is a reason for abstracting data other than transferring information from one location or person to another? To reduce the volume of data.
True or False - keeping track of a paper-based record requires controls. TRUE
Incomplete record processing is an example of what type of control. Corrective
A list of activities that show the date and time and a complete list of activities that have taken place is called what? An audit trail
This refers to what happens to the patient data after the patient is discharged. Post-discharge processing
Compiling, indexing, or cataloging, and maintaining a physical or electronic location for data is called what? Storage
This was developed and implemented to fix an error once it has been detected. Corrective Control
True or False - a paper-based record moves virtually every time someone touches it. TRUE
True or False - the proper way to correct an error in a medical chart is to draw a line through the error and then add the correct information along with the date and the initials of the person making the correction. TRUE
Safety and confidentiality of data refers to what? Security
Define root cause analysis. The procedure used to determine the cause of an error.
True or False; assembly is not necessary in a paper-based record system. FALSE
Ability to retrieve data; release of data only to appropriate individuals or other entities refers to what? Access
A set of procedures by which a record is reorganized post-discharge and prepared for storage is what? Assembly
What is used to keep track of a file that is out of the filing system. Outguide
A doctor's office is an example of what type of setting? Ambulatory care
A missing element is called what? Deficiency
Non-compiled sheet of a medical record are called what? Loose sheets
True or False - The emergency department is not an ambulatory setting. FALSE
True or False - Handling loose sheets is not a full time job. FALSE
Transitional, Skilled nursing, Assisted living are examples of what type of facility? Long-term care facility
Give an example of a data collection issue for a long-term care facility. It generates voluminous data on their patients.
Provide examples of the data collection for radiology and laboratory data sets. x-ray films, computer image, fluid samples, reports, tests
What facility has no unique data set? Behavioral Health facilities
Preadmission lab and radiology services along with the physical and medical history are data collection for what? Ambulatory Surgery
True or False - regular, systematic sorting and distribution of loose sheets is not necessary to ensure a complete record. FALSE
True or False - When handling the patient's record, it should be moved as much as possible, before the next step in the process is attempted. FALSE
In quantitative analysis, if the information is all there, this refers to what part of the quantitative analysis. Existence
MDS applies to what type of facility? Long-term care facility
Continuous care is a data set for what type of facility? Hospice
Data collection for long-term care includes what? Nursing notes, Medication notes, Therapies services/reports, and Daily notes
List the information that is required to be filed under the Patient's Registration tab. Proof of ID and insurance, demographic data, socioeconomic data, Financial data
What is a SOAP note? Progress notes from the doctor
List the data set for Uniform Ambulatory Care. Patient data, Provider data, Encounter data
True or False - Preventative control is used in a paper based file only. FALSE
Doctors name, address, and profession are considered what type of data items. Provider data
True or False - Radiology and Laboratory care see only inpatients. FALSE
Extensive interview notes which may not be part of the legal file, are part of what data set? Behavioral Health Facilities
Give an example of a clinical professional. Medical Assistant
What information is found in an Operative Report? Preoperative, postoperative data, diagnosis, surgeon and surgeons assistants, procedures and description of the operation.
Where are radiology and laboratory services located? Acute care facilities and inpatient rehabilitation facilities
x-rays, computerized tomography scans, magnetic resonance imaging, and positron emission tomography are considered what type of services? Radiology Services
Personal identification is what type of data item? Patient data
Give an example of a non-clinical professional. Billing and coding specialist
True or False - Behavioral Health facilities have free text in their data collection. TRUE
The author's or appropriate signature or password are present is an example of what part of quantitative analysis? Authentication
Patient's reason for seeing the doctor is what type of data item? Encounter data
__________ and __________ are samples of Laboratory data. Blood and Urine samples
The data are entirely present or missing components refers to what part of quantitative analysis? Completeness
What goes in the radiology section of the medical chart the actual x-ray or the report from the doctor who read the x-ray? The report
What does SOAP stand for. Subjective, Objective, Assessment, Plan
Created by: kbcanarr