Health Record Content Midterm Study Stack

38 terms by CutieMcPretty 

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The primary responsibility of the cancer registrar is to=

ensure the timely, accurate, + complete collection + maintenance of cancer data

A coding specialist ensures that all diagnoses, services, + procedures documented in patient records are coded accurately to=

ensure reimbursement, + for research + statistical purposes

Patient data is organized, analyzed, + maintained by health information managers to=

ensure the delivery of quality health care

Health insurance specialists verify health claims against third-party payer guidelines to=

authorize appropriate payment or refer the clain to an investigator for a more thorough review

Health services managers plan, direct, coordinate, + supervise the delivery of health care. They include specialists who=

direct clinical departments or services

Medical assistants perform routine administrative + clinical tasks, which include=

answering telephones, greeting patients, + arranging outpatient lab tests

Medical staff coordinators usually report directly to the health care facility's administrator, + they are responsible for managing the medical staff office + complying with medical staff bylaws, which means they manage the=

physician crendentialing + recredentialing process

A privacy officer oversees the development, implentation, + maintenance of, + adherence to, an organization's policies + procedures covering privacy of + access to patient health info in compliance with=

federal + state laws

A quality manager coordinates a health care facility's quality improvement program to=

improve patient outcomes

A risk manager investigates incident reports to=

recommend appropriate corrective action

Which is characteristic of inpatient care received under DRGs=

inpatients remain in the hospital until they are well enough to be discharged home

Which is an accurate statement about an Acute Care Facility (ACF)=

they provide a full range of health care services

The primary function of hospitals is to provide inpatient medical + nursing services=

along with other services

A consideration when discussing hospital organization is to identify the "population served by a health care facility." This means that health care is provided to specific groups of people. Which is a true statement=

the inpatient bed size licensed by the state determines whether the hospital is general or specialized

To calculate an inpatient length of stay (LOS), count the day of admission but not the day of discharge. A patient admitted on July 25 + discharged on August 3 has which LOS=

9 days

Hospitals categorized as critical access hospitals (CAH) are=

located more than 35 miles from any hospital or another CAH

Which is characteristic of general hospitals=

they provide emergency care, perform general surgery, + admit patients for a range of problems from fractures to heart disease, based on licensing by the state

Physicians who spend most of their time in a hospital setting admitting patients to their inpatient services from local primary care providers are called=

hospitalists

Outpatients are tested + released the same day + do not stay overnight in the hospital. Their length of stay (LOS) is a maximum of=

23 hours, 59 minutes, + 59 seconds

Ambulatory surgery patients undergo certain procedures that can be performed on an outpatient basis, which means the patient is=

treated + released the same day

Which is the goal of both manual + electronic patient records=

documentation of patient care

Which is most important for medicolegal purposes=

entire record

Although hospital inpatient records have traditionally served as the documentation source + business record for patient care info=

all patient records contain similar content + format features

Information capture is the process of recording representations of human thought, perceptions, or actions in documenting patient care, as well as device-generated info that is gathered or computed about a patient as part of health care. Which is an example of information capture=

generating images through x-rays

The primary purpose of the patient record is to provide continuity of care, which means=

documenting services so others have a source from which to base care

The medical record is the property of the provider but the information on it belongs to who=

the patient

The hospital inpatient record documents the care + treatment received by a patient admitted to the hospital. Where is the paper-based record stored while the patient is in the hospital=

the inpatient record is typically located at the nursing station

The standards development organization that creates electronic health record standards under the direction of the U.S. Department of Health + Human Services is called=

HL7

Raw facts that are not interpreted or processed, such as numbers, letters, images, symbols, + sounds are called=

characters

Adult day care=

provides care + supervision in a structured environment to seniors with physical or mental limitations

Assisted- living facility (ALF)=

a combination of housing + supportive services including personal care for seniors

SOAP stands for=

Subjective= patient's statement about how she feels
Objective= observations about the patient, such as physical findings or lab or x-ray results
Assessment= judgment, opinion, or evaluation made by the doctor
Plan= diagnostic, therapeutic to resolve the problem

A group of characters forms a=

field

A collection of records is a=

file

Raw facts=

data

The face sheet is also known as=

admission/discharge record

Final diagnosis=

the diagnosis determined after evaluation

Admitting diagnosis=

also known as provisional diagnosis is the condition or disease for which the patient is seeking treatment

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