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MOT 124
CH 4-5-7
| Question | Answer |
|---|---|
| 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
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