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What is the purpose for a Confidentiality Statement in the health records? A formal agreement in secrecy/ nondisclosure that is signed to protect patient’s information including his/her diagnosis, procedures, discharge status, financial statements
Records gathered directly from the patient and his or her providers that document the patient's history and state of health are: Primary Records
Identify the term used to describe the capability of allowing information to be found efficiently. Retrievability
A final progress note is appropriate as a discharge summary for a hospitalization in which the patient: was an obstetric admission with a normal delivery and no complications
Which of these data sets is used to collect data about ambulatory care patients? UACDS
The method of organizing health records with all of the physician notes together, the physician orders together, the nurses notes together, the medication sheets together, and the laboratory reports together, is known as: Source Oriented
What is a secondary patient record? it is derived from primary record and contains selected data
Paper medical records are usually destroyed by: Shredding and Incinerating
Which of the following is used to gather data about Medicare benificiaries receiving home care? UACHDS
Patients who have a condition requiring an overnight stay for one or more days would typically be treated in a(n): acute care facility
To minimize and detect filing errors, labels are often: Color Coded
Records that are created by abstracting and summarizing information from primary records are: Secondary Records
According to OSHA, the aisle between filing or shelving units must be at least ________ feet wide. 3
It is the responsibility of the ________ to ensure each patient is assigned a unique chart number. HIM Department
Health Care data is classified into one of the following categories? Aggregate
If a patient undergoes an inpatient procedure, and the final summary diagnosis is different from the diagnosis on the pathology report, the coder should: Query the attending physician as to the final diagnosis.
Information from health records is often used to track: Birth, Child Abuse, Exposure to hazardous materials, Communicable Diseases
The length of time that records are kept depends on: contract obligations,policies of the facility,state law,age of the patient.
According to the UHDDS, the definition of secondary diagnosis is a condition that: Receives clinical evaluation, therapeutic treatment, further evaluation, extends the length of stay, increases nursing care
Which term refers to information that is not altered in anyway, so that it is accessible when needed for subsequent care and other legitimate purposes? Integrity
The assembly and analysis of discharged patient records is called incomplete record processing
The physician collecting and recording the patient's data must authenticate the data. From the following, which is NOT a way to authenticate data: A rubber stamp with signature
Without a signed consent, the health record can be accessed by: Health professionals directly involved in case
What is the primary function of the health record? continuity of care
Who is the organization that publish accreditation standards that list basic record content requirements? Joint Commission, Accreditation Association for Ambulatory Health Care (AAAHC),National Committee for Quality Assurance (NCQA)
What type of record will have both a paper and computerized component? Hybrid
CARF accredits programs and service in: Medical rehabilitation and behavioral health
Which is an example of clinical data? Diagnosis
A form of authentication by an individual in addition to the signature by the original author is known as a(n) Countersignature
The JCAHO requires that the history and physical examination be documented in the patient record within ____ of inpatient admission. 24 Hours
The JCAHO requires patient records to be completed ____ days after a patient is discharged. 30
A risk manager needs to locate full documentation of a patient’s fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information Incident Report
14. Based upon the following documentation in an acute care record, where would ou expect this excerpt to appear?“With the patient in supine position, the right side of the neck was appropriately prepped with betadine solution and draped.” Operative Record
In determining your acute care facility’s degree of compliance with prospective payment requirements for Medicate, the best source to reference for recent certification standards would be the: Federal Register
The Medicare program was established in: 1965
What is the total number of MDCs? 25
Medicare is administered by: CMS
A facility is reviewing its policies and procedures to ensure that they comply with JCAHO standards. This facility is concerned about its: Accreditation
The state approves the number of beds a hospital is allowed to have as part of its: Licensure
The number of beds that the facility actually has set up, equipped, and staffed is the: Bed Count
All health care professionals must adhere to their discipline’s ____ standards. Professional
Created by: sweetpixie0280