WGU BDV1 Mod 4 Health Data Management across the continuum (AHIMA C2V3)
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| A health record available electronically allowing communication across providers and permitting real-time decision making. | Electronic Health Record (EHR)
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| A health record that uses components of both paper and electronic systems. | Hybrid Health Record
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| What are the 2 parts of a health record? | Clinical and Adminstrative
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| Which of the following is a health record not used for? (Patient Care, Provider Commication, Evaluating Care, Disease Management, Substantiating Billing Claims, Legal Interests) | Disease Management
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| Which of the sources for standards documentaiton is missing? (Facility Standards, Licensure Standards, Accreditation Standards) | Government Reimbursement Programs
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| Documents the patient's current complaints and symptoms and lists past medical, personal, and family history. | Medical History
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| Represents the attending Phy's assessment of the patient's current health status. | Physical Exam Report
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| Documentaiton of clinical ovservations usually found in an acute care setting. | Progress Note
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| This is assumed when a patient voluntarily submits to treatment. | Implied Consent
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| This is in effect when consent is given either spoken or written. | Expressed Consent
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| This document notes any preoperative medication and response to it, the anesthesia administered with dose and method of administration, duration of administration, and patient's vital signs while under anesthesia. | Anesthesia Report
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| This document describes the surgical procedures performed on the patient and is dictated ot written by the surgeon following the procedure. | Operative Report
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| This document includes the postanesthesia note, nurses's note regarding patient's condition, surgical site, vital signs, fluids given, and monitoring. | Recovery Room Report
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| This document provides a concise account of the patient's illness, course of treatment, response to treatment, and condition at the time of discharge from the hospital. | Discharge Summary
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| What documents the continuity of care, supports activities for medical staff review, and concise information used to answer requests for information by authorized indivudlas or entities. | Discharge Summary
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| This is obtained from patients or legal representatives before providing care or services in emergency situations. | Consent to treatment
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| Privacy legislation has made this document a matter of facility choice. | Consent to treatment
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| The privacy rule requires providers to secure the patient's written acknowledgement that he or she has received this document. | Notice of Privacy Practices (NPP)
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| This document allows the healthcare facilty to verbally disclose or send health informaiton to other organizations (other than those provided as part of HIPAA). | Authorization to disclose information
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| This is a legal document that contains the patient's choice for legal representative for healthcare purposes. | Advanced Directive
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| These physician orders should be consistent with the patient's advanced directives. | Do Not Resuscitate (DNR) and Do Not Attempt Intubation (DNI)
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| This regulation includes acknowledgment forms used to document the patient received information about their rights while a patient. | Patient's Bill of Rights
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| This is another name for the Patient's Bill of Rights. | Medicare Conditions of Participation
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| What term refers to state or county regulations that healthcare facilities must meet to be permtted to provide care? | Licensure
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| Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment actin steps? | Care Plan
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| An APGAR Score is likely found in what type of chart? | Newborn
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| This organization issues specific health informaiton standards for acute care hopitals. | JCAHO
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| This organization issues specific health informaiton standards for rehab hospitals | CARF
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| Ambulatory care records typically includes this document to facilitate ongoing patient care management, but it isn;t typically included on acute care records. | Problem List
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| This ambulatory care document describes current and past illnesses and conditions as well as procedures a patient has undergone. | Problem List
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| Some physican practices use this to collect past medical history informaiton from the patient. | Patient history questionnaire
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| Name an accreditation agency that may have documentation standards for an ambulatory care setting? | Accreditation Association for Ambulatory Health Care (AAAHC)
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| Name an accreditation agency that may have documentation standards for an ambulatory care setting? | JCAHO
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| Name an accreditation agency that may have documentation standards for an ambulatory care setting? | American Osteopathic Association (AOA)
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| Name an accreditation agency that may have documentation standards for an ambulatory care setting? | National Committee for Quality Assurance (NCQA)
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| Which type of record might include sexual practices? | Obstetric/Gynecologic
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| This care plan format is used by SNF's and includes the MDS. | Resident assessment instrument (RAI)
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| The RAI includes MDS, triggers, utilization guidelines, and _______ ________ ________. | Resident assessment protocols (RAPs)
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| Medicare uses this form in a long term facility to determine reimbursement. | Minimum Data Set (MDS)
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| Medicare certified home health agencies use this standardized patient assessment insrutment for the plan of care and reimbursement. | Outcomes and Assessment Informaiton Set (OASIS)
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| Care provided to terminally ill patients and supportive services to patients and families. | Palliative Care
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| This document is completed shortly after admisison and upon discharge to an inpatient rehab facility. | Patient assessment instrument (PAI)
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| Medicare requires this for various settings of care for End-Stage Renal Disease. | Conditions of Coverage
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| An electronic, universally available, lifelong resource of health information needed by individuals to make health decisions. | Personal Health Record
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| Which type of health record contains information about care provided prior to arrival at a healthcare setting and documentaiton of care provided to stabilize the patient? | Emergency Care
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| Patient history quesionnaires, problem lists, diagnostic test results, and immunization records are found in which type od record? | Ambulatory Care
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| Ambulatory surgery record contains information most similar to ___________. | Hospital operative records
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| Which standardized tool is used to assess Medicare-certified rehab facilities? | Patient assessment instrument (PAI)
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| Records in which setting would not include an interdisciplinary care plan? | Ambulatory care
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| Portions of a treatment record may be maintained in a patient's home for which settings of care? | Home Health and End-Stage Renal Disease
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| Paper records may require thenning in which two settings? | Long Term Care and Correctional Serevices
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| In 2004 JCAHO implemented a new survey process called Shared Visions-New Pathways to bring what changes? | Continuous improvement and compliance, streamlined survey paperwork, midcycle reviews, sentinel events monitoring, and tracer methodology
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| Accreditation manuals often include documentation standards in a section called what? | Management of Information
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| The American Osteopathic Association (AOA) originally began for what purpose? | Ensure the quality of residency programs for their doctors.
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| Which of these services are not accredited by CARF? (Medical Rehab, End-Stage Dialysis, Assisted Living, Behavorial Health, Adult day care, employment and community centers) | End-Stage Dialysis Centers
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| What organization accreditates Managed Care and Preferred Provider Organizations starting in 1991? | National Committee for Quality Assurance (NCQA)
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| Organizations receiving funding for services to Medicare patients must comply with what? | Medicare Conditions of Participation
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| The Medicare Conditions of Participation requires that Medical History and Physical exam be completed no more than _____ days before or _____ hours after admission. | 30, 24
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| What is the correct section of the medical record to contain Vital Signs? | Objective section of a SOAP note
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| What is the correct section of the medical record to contain the marital status and occupation? | Social history of a Medical History
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| What is the correct section of the medical record to contain the referral of the patient to a physical therapist for treatment? | Plan section of a SOAP note
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| What is the correct section of the medical record to contain the Systematic Inventory? | Review of systems portion of a Medical History
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| What is the correct section of the medical record to contain the directions for follow up? | Discharge Summary
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| What organization is the source of documentation standards or guidelines for Long Term Care facility? | Joint Commission
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| What organization is the source of documentation standards or guidelines for Osteopathic residency programs? | AOA
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| What organization is the source of documentation standards or guidelines for Ambulatory care? | AAAHC
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| What organization is the source of documentation standards or guidelines for Rehabilitation hospital? | CARF
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| What organization is the source of documentation standards or guidelines for Managed care assessment of in-plan providers? | NCQA
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| Which of the medical record form/report summarizes the patient's medical and surgical conditions? | Problem List
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| Which of the medical record form/report is a component of the medical history? | Chief complaint or reason for visit
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| Which of the medical record form/report describes surgical procedures performed? | Operative Report
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| Which of the medical record form/report is a written opinion provided by one physician to another? | Consultation Report
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| Which of the medical record form/report an be integrated or source-oriented? | Progress Note
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| In a SOAP Note, what is the "S" represent? | Subjective: Patient's complaints and comments
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| In a SOAP Note, what is the "O" represent? | Objective: Physical findings and laboratory data
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| In a SOAP Note, what is the "A" represent? | Assessment: Diagnosis and impression
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| In a SOAP Note, what is the "P" represent? | Plan: Medication, therapy, referral, consultation, and patient education
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