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 | show 🗑
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| show | 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 | show 🗑
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| discharge summary documentation must include | show 🗑
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| show | quality of care through the use of pre-established criteria
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| show | 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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| show | 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 | show 🗑
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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. | show 🗑
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| show | 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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| show | 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" | show 🗑
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| show | 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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| show | 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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| show | 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 | show 🗑
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| show | 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? | show 🗑
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| show | outcome measures
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| engaging PT's and their families in health care decisions is one of the core objectives for... | show 🗑
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