PRG 2017/ Health Data Content and Standards
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| 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? | show 🗑
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| show | Cognitive Patterns
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| Joint Commission used to focused on promoting the use of facility approved abbreviations. Now the focus have shifted to.. | show 🗑
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| Engaging patients and their families in the health care decisions is one of the core objectives for... | show 🗑
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| show | incident report
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| For continuity of care, ambulatory care providers are more likely than providers of acute care service to rely on the documentation found in the... | show 🗑
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| Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that... | show 🗑
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| 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... | show 🗑
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| 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... | show 🗑
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| show | disease index
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| show | interns or medical students
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| The minimum length of time for retaining original medical records is primarily governed by | show 🗑
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| CDI (clinical documentation improvement) programs may work together with UM (utilization management) programs to | show 🗑
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| show | significant findings during hospitalization
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| show | quality of care through the use of pre established criteria
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| show | the attending MD (the provider)
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| 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... | show 🗑
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| show | interdisciplinary plan of care
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| show | ONC (office of the national coordinator for HIT)
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| show | marking the surgical site
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| show | meaningful use requirements
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| 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 | show 🗑
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| show | noncompliance with Joint Commission Standards
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| 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... | show 🗑
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| show | operation index
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| show | nurses using bedside terminals to record vital signs
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| show | bar code placement
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| 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... | show 🗑
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| show | data accuracy
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| 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... | show 🗑
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| show | precision
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| show | Federal Register (published by CMS)
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| show | a legible copy of a current H&P performed in the attending MD's office is available
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| 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? | show 🗑
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| show | RIO (Regional Health Information Organization)
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| show | OCR (Office for Civil Rights ensures equal access to certain health and human services and protects the privacy and security of health information)
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| 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... | show 🗑
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| show | APGAR score
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| show | downward adjustments to Medicare reimbursement
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| show | needs of the user
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| show | when the director of health records is acting in response to a subpoena duce tecum and takes the health record to court
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| Using the SOAP style of documenting progress notes, choose the subjective ( statement from the following | show 🗑
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| show | MDS (minimum data set)
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| show | facility's data dictionary
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| 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 | show 🗑
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| 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... | show 🗑
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| What are the documentation standards set by Joint Commission for documenting a H&P | show 🗑
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| show | Operative Record
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| show | Analyst
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| show | Yes, prior to surgery
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| show | point of care documentation
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| show | health record
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| show | general appearance as assessed by the physician
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| show | qualitative review
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| show | discrepancy between post op diagnosis by the surgeon and pathology diagnosis by the pathologist
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| show | impressions of a cardiologist asked to determine whether patient is a good surgical risk.
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| 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 | show 🗑
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| 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... | show 🗑
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| In your facility the health are providers from every discipline document progress notes sequentially on the same form. Your facility is utilizing. | show 🗑
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| Which of the following services is LEAST likely to be provided by a facility accredited by CARF (Commission Accredited Rehab Facility) | show 🗑
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kodom001