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RHIA Chap 1
PRG 2017/ Health Data Content and Standards
Question | Answer |
---|---|
In preparation for and EHR, You must name each form for bar coding and indexing into a document management system Then unnamed document in front of you includes a microscopic description of tissue excised during surgery. What is this report? | Pathology Report |
Patient data collection requirement vary according to health care setting. A data element you would expect to be collected in the S, but not the UHDDS would be... | Cognitive Patterns |
Joint Commission used to focused on promoting the use of facility approved abbreviations. Now the focus have shifted to.. | Use of prohibited or dangerous abbreviations |
Engaging patients and their families in the health care decisions is one of the core objectives for... | achieving meaningful use of EHR |
RM needs to locate a full report of a patients fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this info in the... | incident report |
For continuity of care, ambulatory care providers are more likely than providers of acute care service to rely on the documentation found in the... | problem list |
Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that... | Evidence cannot be provided that the MD actually reviewed and approved each report |
As a part of a QI study, you have been asked to provide info on the menstrual history, # of pregnancies, and # of living children on each OB patient from a stack of old obstetrical records. The best place to locate this info is the... | prenatal record |
As a concurrent record reviewer for an acute care facility, you have asked MD to provide and updated H&P for one of her recent admissions. MD provides a copy of an H&P done a week before admission. You tell the MD... | the H&P is acceptable as long as any interval changes were documented |
You have been asked to identify every reportable case of cancer form the previous year. A key resource will be the facility's... | disease index |
Joint commission requires the attending MD to countersign health record documentation that is entered by... | interns or medical students |
The minimum length of time for retaining original medical records is primarily governed by | state law |
CDI (clinical documentation improvement) programs may work together with UM (utilization management) programs to | reduce clinical denials for medical necessity |
Discharge summary documentation must include.. | significant findings during hospitalization |
the performance of ongoing record reviews is an important tool in ensuring data quality. These reviews evaluate... | quality of care through the use of pre established criteria |
Ultimate responsibility for the quality and completion of entries in patient health record belongs to... | the attending MD (the provider) |
The federally mandated resident assessment instrument used in LTC facilities consists of three basic components, including the new care area assessment, utilization guidelines and the... | MDS (minimum data set) |
The foundation for communicating all patient care goals in LTC settings is the .... | interdisciplinary plan of care |
you are investigating the workforce development projections of EHR specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need to regularly access the web site of this governmental agency | ONC (office of the national coordinator for HIT) |
As part of J.C National Patient Safety goal initiative, hospitals must use a Pre Op verification process to confirm the patients identity & confirm that necessary documents (ex. med records) are available . They must also develop an use a process for... | marking the surgical site |
One of the patients at your MD group practice haw asked for an electronic copy of their medical record. Your electronic computer system will not allow you to accommodate this request. Chances are, you are NOT in compliance with... | meaningful use requirements |
One of J.C National Patient Safety Goals (NSPGs) require that healthcare facilities eliminate wrong site, wrong patient & wrong procedure surgery. To accomplish this, which of the following would NOT be considered part of a preop verification process | follow the daily surgical patient listing for surgery suite if the patient has been sedated. |
A qualitative record review revealed that a H&P for a patient admitted on 6/26 was performed on 6/30 and transcribed on 7/1. Which of the following statements regarding the H&P is true in the situation. Completion and charting of the H&P indicates... | noncompliance with Joint Commission Standards |
The final HITECH Omnibus Rule expanded some of HIPAA's original requirements, including changes in the immunization disclosures. As a result, where states require immunization records of a minor prior school admission, the school can... | Simply document a written or oral agreement form a parent or guardian before releasing the immunization record to the school |
you have been asked by a peer review committee to print a list of the medical record numbers of all patients who had CABGs performed in the past year at your facility. which secondary data source could be used to quickly gather this info. | operation index |
the best example of point of care service and documentation is | nurses using bedside terminals to record vital signs |
principles of forms design apply to paper base and EHR systems. the physical layout of the form or screen should be organized to match how info is requested. Facilities that are scanning and imaging paper records as part of a EHR must give consider | bar code placement |
which of the following is a form or view that is typically seen in the health record of a LTC patient but is rarely seen in records of acute care patients... | pharmacy consultation |
The health record sates that the patient is a female, but the registration record has the patient listed as male. Which of the following characteristics of data quality has been compromised in this case? | data accuracy |
The first patient with cancer seen in your facility on 1/1/2015 was diagnosed with colon caner with no known history of previous malignancies. The accession number assigned to this patient is... | 15-0001/01 (the first number represents the year the patient entered the database- the second number represents what case number it was for the year, the third number represents the number of known neoplasms) |
Setting up a drop down menu to make sure that registration clerk collects gender as male, female or unknown is an example of ensuring data.... | precision |
In determining you acute care facilities degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certifications standards is the... | Federal Register (published by CMS) |
In an acute care hospital, a complete H&P may not be required for a new admission when... | a legible copy of a current H&P performed in the attending MD's office is available |
You are developing a complete data dictionary for your facility. Which of the following resources will be most helpful in proving standard definitions for data commonly collected in acute care hospitals? | Uniform Hospital Discharge Data Set |
Gerda smith has presented to the ER I a coma with injuries sustained in a motor vehicle accident. Gerda has had a recent medical history taken at the public health department. The MD on call is grateful that she can access this info using... | RIO (Regional Health Information Organization) |
Currently, enforcement of HIPAA Privacy and Security Rules is the responsibility of the.... | OCR (Office for Civil Rights ensures equal access to certain health and human services and protects the privacy and security of health information) |
A key data item you would expect to find recorded on an ER record but would probably NOT find in an acute care record is... | time and means of arrival |
A data item to include on a qualitative review checklist of newborn inpatient health records that need not be included on adult records would be.. | APGAR score |
You're a coding director at a large group practice. The manager stops by to ask about complying with HITECH req. to adopt to meaningful use EHR tech. The incentives were from 2011-2014. By 2015, sanctions for non compliance will appear in the form of | downward adjustments to Medicare reimbursement |
In creating a new form or computer view, the designer should be most driven by... | needs of the user |
Under which of the following conditions can an original paper based patient health record be physically removed from the hospital | when the director of health records is acting in response to a subpoena duce tecum and takes the health record to court |
Using the SOAP style of documenting progress notes, choose the subjective ( statement from the following | patient states low back pain is as severe as it was on admission (S=subjective: what the patient says is wrong) |
IN 1987, OBRA helped shift the focus in LTC to patient outcomes. As a result, core assessment data elements are collected on each SNF resident as defined in the | MDS (minimum data set) |
As Chair of a Forms Review Committee, you need to track the field name of a particular data field and the security levels applicable tot hat field. Your best source for this info would be the | facility's data dictionary |
You notice on the H&P that the patient was admitted for disc surgery, but the PN indicate that due to some hear irregularities, he may not be a good surgical risk. Because of your knowledge of COP regulations, what should be added to his record | consultation report |
A major contribution to a successful CDI program is the ability to demonstrate the impact that documentation has on data reporting to the facility's staff. IN this role, the CDI specialist is acting as a... | auditor |
What are the documentation standards set by Joint Commission for documenting a H&P | 24 hours after admission or prior to surgery |
where would you expect to find this - " with the pt in the supine position, the right side of the neck was appropriately prepped with betadine solution and draped. I was able to pass the central line, which was taped to skin..." | Operative Record |
A CDI Specialist performs many duties. These include reviewing the data, and looking for trends or pater over time, as well as noting any variances that require further investigation. IN this role, the CDI professional is acting as an.. | Analyst |
JC standards require that a complete H&P be documented on the health records of operative patients. Does this report carry a time requirement? | Yes, prior to surgery |
The flagging records for deficiencies and requiring retrospective documentation add little to no value to patient care. You encourage MD to document a the time and location of service instead of waiting to be flagged for a deficiency. This is called | point of care documentation |
An example of a primary data source for health care statistics is the | health record |
In the computerization of forms, good screen design, along with the options of alerts and alarms, makes it easier to ensure all data items have been captured. one essential item on the physical exam is... | general appearance as assessed by the physician |
During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day 4 of hospitalization there was one missed does of insulin. What type of review is this clerk performing? | qualitative review |
Which of the following is least likely to be identified by a retrospective quantitative analysis of a health record? | discrepancy between post op diagnosis by the surgeon and pathology diagnosis by the pathologist |
The Conditions of Participation requires that the medical staff bylaws, rules, and regulation address he status of consultants. Which of the following reports would normally be considered a consultation. | impressions of a cardiologist asked to determine whether patient is a good surgical risk. |
The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely include checking for documentation regarding | the presence or absence of such items as preoperative and postoperative diagnosis, description of findings and specimens removed |
In your facility it has become critical that information regarding patients how are transferred to the oncology unit be sent to an outpatient scheduling system to facilitate outpatient appointments. This info can be obtained most efficiently from... | R-ADT System (Registration Admission Discharge Transfer System) |
In your facility the health are providers from every discipline document progress notes sequentially on the same form. Your facility is utilizing. | integrated progress notes |
Which of the following services is LEAST likely to be provided by a facility accredited by CARF (Commission Accredited Rehab Facility) | Palliative Care |