CCS health data content and standards
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| patient data collection requirements vary according to health care setting. a data element you would expect to be collected in the MDS but not in the UHDDS would be | cognitive, hearing, vision, moods, ect. MDS=minimum data set, it captures data on nursing home patients.
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| in the past joint commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. with the advent of he commissions national patient safety goals, the focus has shifted to.... | use of prohibited or "dangerous" abbreviations
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| as part of a quality improvement study you have been asked to provide information on the menstrual history, number of pregnancies, number of living children on each OB patient from old records. the best place in the record to find this information is the | prenatal record.the prenatal record should have a comprehensive H&P with attention to menstrual and reproductive history.
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| discharge summary documentation must include | significant findings during hospitalization.
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| the performance of qualitative analysis is an important tool in ensuring data quality. these reviews evaluate | quality of care through the use of pre-established criteria
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| ultimate responsibility for the quality and completion of entries in patient health records belongs to the | the attending physician. although the nursing staff, hospital administration, and the health information management professional play a role in ensuring an accurate and complete record, the major responsibility lies with the attending physician.
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| according to the joint commission's national patient safety goals, which of the following abbreviations would most likely be prohibited?a) 0.04 b) 4 mg c) 40 mg d) 0.4 mg | d) 0.4 abbreviations considered confusing or likely to be misinterpreted are those with a leading decimal.
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| in determining your acute care facility's degree of compliance with prospective payment requirements for medicare,the best resource to reference for recent cerification standards is the | Federal Register. CMS publishes both proposed and final rules for the conditions of participation for hospitals in the federal register.
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| on the admission H&P that Mr. McKahan, a medicare pt, was admitted for disc surgery the progress notes say "due to some heart irregularities, he's a surgical risk". with your knowledge of COP regulations a _______ will be added to his health record. | consultation report. COP requires this report on PT's who are not a good surgical risk and those with obscure dx's, pt's whos physicians have doubts as to the best therapeutic measure to use, & pt's if there is a question of criminal activity.
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| during a retrospective review of an inpatient health record, the health info clerk notes that on day 4 of hospitalization there was on missed dose of insulin. what type of review is this clerk performing? | QUALItative analysis checks documentation consistency, such as comparing a pt's pharmacy drug profile with the medication administration record. QUANTItive analysis checks for presence or absence of reports.
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| which indices might be protected from unauthorized access through the unique identifier odes assigned to members of the medical staff? A) disease B) procedure C) master patient D) physician | D) information contained in the physicians' index is considered confidential, identification codes are often used rather than the physicians' names.
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| what are the 3 stages of "meaningful use" | 1) data capture and sharing
2) advance clinical processes
3) improve outcomes
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| you recommend that the staff routinely check to verify that a summary on each pt is provided to the attending physician so that he/she can review, update, and recertify the pt as appropriate. the time frame for requireing this summary is at least every | 60 day time frame is often referred to as the pt's certification period. re-certification can continue every 62 days until the pt is discharged from home health services.
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| what is the document in you facility that spells out the documentation requirements for pt records, designate the time frame for completion by the active medical staff, and indicate the penalties for failure to comply with these record standards | the medical staff rules and regulations outline the details for implementing the principles of the staff bylaws, they include the process and time frames for completing records, and the penalties for failure to comply to the bylaws.
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| what is the difference between "review of systems" and "physical exam" | the "review of systems" documents subjective symptoms that the pt may have forgotten to mention or that may have seemed unimportant while the physical exam is objective symptoms observed by the physician.
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| case finding methods for pt's with diabetes include a review of all but.. A)health plans B) CPT DX codes C) billing data D) RX list | B) CPT DX codes
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| the protection of a PT's health info is addressed all but one A) HIPPA B) privacy act C) drug abuse & treatment act D) U.S. patriot act | D) U.S. patriot act is about prevention of terrorism.
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| while performing routine quantitative analysis of a record, an employee finds an incident report in the record. what should the employee do with it? | refer this record to the risk manager for further review and removal of the incident report
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| PT mortality, infection and complication rates, adherence to living will requirements, adequate pain control, and other documentation that describe end results of care or a measurable change in the PT's health are examples of | outcome measures
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| engaging PT's and their families in health care decisions is one of the core objectives for... | achieving meaningful use of EHR's
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