In preparation for an EHR, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is
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
In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to the
use of prohibited or "dangerous" abbreviations
Engaging patients and their families in health care decisions is one of the core objectives for
achieving meaningful use of EHRs.
A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the
For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the
Joint Commission does not approved of auto authentication of entries in a health record. The primary objection to this practice is that
evidence cannot be provided that the physician actually reviewed and approved each report.
As part of a quality improvement study, you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records. The best place in the record to locate this information is the
As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admission. Dr. Crossman pages through the medical record to a copy of an H & P performed in her office a week before admission. You tell Dr. Crossman
the H & P copy is acceptable as long as she documents any interval changes
You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility's
Joint Commission requires the attending physician 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
The use of personal signature stamps for authentication of entries in a paper-based record requires special measures to guard against delegated use of the stamp. In a completely computerized patient record system, similar measures might be utilized to govern the use of
The performance of qualitative analysis is an important tool in ensuring data quality. These reviews evaluate
the overall quality of documentation
Ultimate responsibility for the quality and completion of entries in patient health records belongs to the
The federally mandated resident assessment instrument used in long-term care facilities consists of three basic components, including the new care area assessment, utilization guidelines, and the
The foundation for communicating all patient care goals in long-term care settings is the
interdisciplinary plan of care
As the Director of a Health Information Technology Program, your community college has been selected to participate in the workforce development of electronic health record 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
As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity, and to confirm that necessary documents such as x-rays or medical records are available. They must also develop and use a process for
marking the surgical site
In preparing your facility for initial accreditation by the Joint Commission, you are trying to improve the process of ongoing record review. All health record reviews are presently performed by a team of HIM department personnel. The committee meets quarterly and reports to a Quality Management Committee. In reviewing Joint Commission standards, your first recommended change is to
provide for record reviews to be performed by an interdisciplinary team of care providers
According to the Joint Commission's National Patient Safety Goals, which of the following abbreviations would most likely be prohibited.
A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the history and physical is true in this situation? Completion and charting of the H & P indicates
noncompliance with Joint Commission standards
Using the SOAP method of recording progress notes, which entry would most likely include differential diagnosis?
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 acute care hospital. Which secondary data source could be used to quickly gather this information?
The best example of point-of-care service and documentation is
nurses using bedside terminals to record vital signs
Many of the principles of forms design apply to both paper-based and computer-based systems. For example, the physical layout of the form and / or screen should be organized to match the way the information is requested. Facilities that are scanning and imaging paper records as part of a computer-based system must give careful consideration to
bar code placement
Which of the following is a form or view that is typically seen in the health record of a long-term care patient but is rarely seen in records of acute care patients?
The health record states 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?
The first patient with cancer seen in your facility on January 1, 2012, was diagnosed with colon cancer with no known history of previous malignancies. The accession number assigned to this patient is
Setting up a drop down menu to make sure that the registration clerk collects "gender" as "male, female, or unknown" is an example of ensuring data
In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the
In an acute care hospital, a complete history and physical may not be required for a new admission when
a legible copy of a recent H & P performed in the attending physician's office is available
You are developing a complete data dictionary for your facility. Which of the following resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals?
Uniform Hospital Discharge Data Set
Gerda Smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. According to her sister, Gerda has had a recent medical history taken at the public health department. The physician on call is grateful that she can access this patient information using the area's
When developing a data collection system, the most effective approach first considers
the end user's needs
A key data item you would expect to find recorded on an ER record but would probably NOT see in an acute care record is the
time and means of arrival
A data item to include on a qualitative review checklist of infant and children inpatient health records that need not be included on adult records would be
growth and development records
Under which of the following conditions can an original paper-based patient health record by physically removed from the hospital?
when the director of health records is acting in response to a subpoena duces tecum and take the health record to court
According to the following table, the most serious record delinquency problem occurred in which of the following months?
Using the SOAP style of documenting progress notes, choose the "objective" statement from the following.
patient states low back pain is as severe as it was on admission
In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each SNF resident as defined in the
As the Chair of a Forms Review Committee, you need to track the field name of a particular data field and the security levels applicable to that field. Your best source for this information would be the
facility's data dictionary
You notice on the admission H & P that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate that due to some heart irregularities, he may not be a good surgical risk. Because of your knowledge of COP regulations, you expect that a (n) ___________ will be added to his health record
An example of objective entry in the health record supplied by a health care practitioner is the
You have been appointed as Chair of the Health Record Committee at a new hospital. Your committee has been asked to recommend time-limited documentation standards for inclusion in the medical staff bylaws, rules, and regulations. The committee documentation standards must meet the standards of both the Joint Commission and the Medicare Conditions of Participation. The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report should be set at
24 hours after admission or prior to surgery
Based on the following documentation in an acute care record, where would you expect this excerpt to appear?
"With the patient 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 and used for administration of drugs resuscitation."
A surgeon on the Health Record Committee voices a concern that, although he has been told that the operative report is to be dictated immediately after surgery, he has often had to deal with the problem of transcription backlog, which prevented the report from getting on the health record in a timely manner. Your advice to this doctor is that when a known backlog exists, he should
write a detailed operative note in the record
Joint Commission standards require that a complete history and physical be documented on the health record of operative patients. Does this report carry a time requirement?
Yes, prior to surgery
The old practices of flagging records for deficiencies and requiring retrospective documentation add little or not value to patient care. You try to convince the entire health care team to consistently enter data into the patient's record at the time and location of service instead of waiting for retrospective analysis to alert them to complete the record. You are proposing
In the computerization of forms, good screen view design, along with the options of alerts and alarms, makes it easier to ensure that all essential data items have been captured. One essential item to be captured on the physical exam is the
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 dose of insulin. What type of review is this clerk performing?
Which of the following is least likely to be identified by a deficiency analysis technician?
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 regulations address the status of consultants. Which of the following reports would normally be considered a consultation?
impression of a cardiologist asked to determine whether patient is a good surgical risk
The health care providers at your hospital do a very through 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 diagnosis, description of findings, and specimens removed
In your facility it has become critical that information regarding patients who are transferred to the oncology unit be sent to an outpatient scheduling system to facilitate outpatient appointments. This information can be obtained most efficiently from
In your facility, the health care 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?
Which method of identification of authorship or authentication of entries would be inappropriate to use in a patient's health record?
delegated use of computer key by radiology secretary
Though you work in an integrated delivery network, not all systems in your network communicate with one another. As you meet with your partner organizations, you begin to sell them on the concept of an important development intended to support the exchange of health information across the continuum within a geographical community. You are promoting the you are promoting that your organization join a
regional health information organization
As a trauma registrar working in an emergency department, you want to begin comparing your trauma care services to other hospital-based emergency departments. To ensure that your facility is collecting the same data as other facilities, you review elements from which data set?
As a new HIM manager of an acute care facility, you have been asked to update the facility's policy for physician verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualification of those individuals in your facility who have been authorized to record verbal orders. For this information you will consult the
Hospital Bylaws, Rules, and Regulations
Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of
Accreditation by Joint Commission is a voluntary activity for a facility and it is
required for reimbursement of certain patient groups
Which of the following indices might be protected from unauthorized access through the use of unique identifier codes assigned to members of the medical staff?
Which of the four distinct components of the problem-oriented record serves to help documentation throughout the record?
As supervisor of the cancer registry, you report the to registry's annual caseload to administration. The most efficient way to retrieve this information would be to use
As the Compliance Officer for an acute care facility, you are interested in researching recent legislation designed to provide significant funding for health information technology for your next committee meeting. You begin by googling
Select the appropriate situation for which a final progress note may legitimately be substituted for a discharge summary in an inpatient medical record.
Baby Boy Hiltz, born 1/5/2011, maintained normal status, discharged 1/7/2011
Based on the following documentation in an acute care record, where would you expect this excerpt to appear? " Initially the patient was admitted to the medical until to evaluate the x-ray findings and the rub. He was started on Levaquin 500 mg initially and then 250 mg daily. The patient was hydrated with IV fluids and remained afebrile. Serial cardiac enzymes were done. The rub, chest pain, and shortness of breath resolved. EKGs remained unchanged. Patient will be discharged and followed as an outpatient."
The information security officer is revising the policies at your rehabilitation facility for handling all patient clinical information. The best resource for checking out specific voluntary accreditation standards and guidelines is the
Stage I of meaningful use focuses on data capture and sharing. Which of the following is included in the menu set of objectives for eligible hospitals in this stage?
Use CPOE for medication orders
Which of the following is a secondary data source that would be used to quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months?
As the Coding Supervisor, your job description includes working with agents who have been charged with detecting and correcting overpayments made to your hospital in the Medicare for Service program. You will need to develop a professional relationship with
recovery audit contractors
Using a template to collect data for key reports may help to prompt caregivers to document all required data elements in the patient record. This practice contributes to data
In preparation for an upcoming site visit by Joint Commission, you discover that the number of delinquent records for the preceding month exceed 50% of discharged patients. Even more alarming was the pattern you noticed in the type of delinquencies. Which of the following represents the most serious pattern of delinquencies? Fifteen percent of delinquent records show
missing operative reports
A primary focus of screen format design in a health record computer application should be to ensure that
the user is capturing essential data elements
A quality improvement team is focusing on the unacceptable number of unsigned doctors' orders in your facility. The most effective method for increasing the timeliness of signatures on orders and positively impacting the patient care process would be
developing an open-record review process
Before making recommendations to the Executive Committee regarding new physicians who have applied for active membership, the Credentials Committee must query the
National Practitioner Data Bank
A qualitative analysis of OB records reveals a pattern of inconsistent data entries when comparing documentation of the same data elements captured on both the prenatal form and labor and delivery form. The characteristic of data quality that is being compromised in this case is data
Medicare rules state that the use of verbal orders should be infrequent and used only when the orders cannot be written or given electronically. In addition, verbal orders must be
recorded by persons authorized by hospital regulations and procedures
The lack of a discharge order may indicate that the patient left against medical advice. If this situation occurs, you would expect to see the circumstances of the leave
documented in both the progress notes and the discharge summary
Your committee is charged with developing procedures for the Health Information Services staff of a new home health agency. You recommend that the staff routinely check to verify that a summary on each patient is provided to the attending physician so that he or she can review, update, and recertify the patient as appropriate. The time frame for requiring this summary is at least every
You want to review one document in your facility that will spell out the documentation requirements for patient records, designate the time frame for completion by the active medical staff, and indicate the penalties for failure to comply with these record standards. Your best resource will be
medical staff rules and regulations
A quarterly review reveals the following data for Springfield Hospital:
Average monthly discharges = 1, 820
Average monthly operative procedures = 458
Number of incomplete records = 1,002
Number of delinquent records = 590
What is the percentage of incomplete records during this quarter?
Referring to the date in the previous question, determine the delinquent record rate for Springfield Hospital?
Still referring to the information in the table in question 88 and the delinquent record rate shown in the answer for question 89, would the facility be out of compliance with Joint Commission standards?
In an acute care facility, the responsibility for educating physicians and other health care providers regarding proper documentation policies belongs to the
health information manager first
Documentation found in acute care health records should include core measure quality indicators required for compliance with Medicare's Health Care Quality Improvement Program. A typical indicator for patients with pneumonia is
blood culture before first antibiotic recieved
One record documentation requirement shared by BOTH acute care and emergency departments is
patient's condition on discharge
In addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain
As the Chair of the Forms Committee at your hospital, you are helping to design a template for house staff members to use while collecting information for the history and physical. When asked to explain how "review of systems" differs from "physical exam" you explain that the review of systems is used to document
subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant
Skilled nursing facilities may choose to submit MDS data using RAVEN software, or software purchased commercially through a vendor, provided that the software meets