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Domain 5: Compliance
Terms in this set (47)
Improving the clinical specificity of physician reports through a physician query is a goal shared by the coding staff and the
Ultimate responsibility for the quality and completion of entries in patient health records belongs to the
One of the Joint Commission National Patient Safety Goals (NSPGs) requires that health care organizations eliminate wrong-site, wrong-patient, and wrong-procedure surgery. In order to accomplish this, which of the following would NOT be considered part of a preoperative verification process?
Follow the daily surgical patient listing for the surgery suite if the patient has been sedated.
The final HITECH Omnibus Rule expanded some of HIPAA's original requirements, including changes in immunization disclosures. As a result, where states require immunization records of a minor prior to admitting a student to a school, a covered entity is permitted to
simply document a written or oral agreement from a parent or guardian before releasing the immunization record to the school.
The "Disclosure of Student Immunizations to Schools" provision of the final rule permits a covered entity to disclose proof of immunization to a school (where state law requires it prior to admitting a student) without written authorization of the parent. An agreement must still be obtained and documented, but no signature by the parent is required.
The difference between an Institutional Review Board (IRB) and a hospital's Ethics Committee is that
the IRB deals with the ethical treatment of human research subjects, and the Ethics Committee covers a wide range of issues.
As a new HIM manager of an acute care facility, you have been asked to update the facility's policy for a physician's verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualifications 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.
Joint Commission requires the attending physician to countersign health record documentation that is entered by
interns or medical students.
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 coder for a large physician practice, you have reason to believe that several physicians are involved in charging Medicare for services not rendered. Regulatory oversight for complaints regarding this fraudulent activity lies with
the Recovery Audit Contractor
The goal of the RAC program is to identify and recover improper payments made on claims of health care services.
A major contribution to a successful CDI program is the ability of the CDI specialist to demonstrate to the medical staff as well as to administration the powerful impact that precise documentation has on internal and external data reporting. In this role, he/she is acting as a(n)
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
written within 24 hours of the patient's admission.
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.
As the compliance officer for a large physician practice group, you are interested in researching the original requirements for meaningful use of certified EHRs for use in an upcoming presentation. You begin by googling
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 Fee-for-Service program. You will need to develop a professional relationship with
recovery audit contractors.
An 11-year-old female is brought to the emergency room with a compound, comminuted fracture of the right tibia and fibula. Her mother was very seriously injured in the same accident and is unconscious. What should be done?
Both patients can be treated under implied consent
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
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
The patient's family asked the attending physician to keep the patient in the hospital for a few days more until they could make arrangements for the patient's home care. Because the patient no longer meets criteria for continued stay, if the physician complies with the family's request, this would be considered
an inappropriate use of hospital resources.
What quality indicator would prove useful in tracking customer satisfaction in the correspondence/release of information function?
the turnaround time from the date a request is received to the date the information is provided to the requester
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 admissions. 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 that
the H&P copy is acceptable as long as she documents any interval changes.
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
Your facility has a team that has been working to develop a strong performance improvement model, and they have come up with the model shown above. The team asks if you see anything missing from the model. You tell them they
are missing a step requiring ongoing monitoring and reassessment.
Joint Commission standards require that a complete history and physical be documented on the health records of operative patients. Does this report carry a time requirement?
yes, prior to surgery
In preparation for an upcoming site visit by Joint Commission, you discover that the number of delinquent records for the preceding month exceeded 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
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
Which of the following is least likely to be identified by a retrospective quantitative analysis of a health record?
discrepancy between postoperative diagnosis by the surgeon and pathology diagnosis by the pathologist
Which of the following services is LEAST likely to be provided by a facility accredited by CARF?
As a working HIM professional, you are investigating the workforce development projections 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 website of this governmental agency.
The HIM Department at General Hospital has been experiencing an average 30-minute delay in the retrieval of records requested by the Emergency Department. Which of the following corrective actions would be most effective in reducing the delay in retrieval of requested records?
Review and possibly reengineer the retrieval process to decrease retrieval time.
A transcription unit has been asked to tally the number of times they have to leave sections of a report blank for various reasons (poor dictation technique, background noise, etc.). The quality improvement tool most likely to help collect these data would be
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
Which of the following reports would normally be considered a consultation?
impressions of a cardiologist asked to determine whether patient is a good surgical risk
Improving clinical outcomes and optimal continuity of care for patients are common goals of clinical documentation improvement programs in acute care hospitals. Additionally, CDI programs may work together with UM programs to
reduce clinical denials for medical necessity.
Parker has type 1 diabetes with hypertension that is currently controlled with medication. Parker was admitted through the ED for an emergency appendectomy. Following surgery, the patient developed an infection at the wound site that was treated with antibiotics. When making decisions about sequencing the codes for this case, the coder should rely on definitions found in the
Currently, the enforcement of HIPAA Privacy and Security Rules is the responsibility of the
Office for Civil Rights.
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
A clinical documentation specialist performs many duties. These include reviewing the data and looking for trends or patterns over time, as well as noting any variances that require further investigation. In this role, the CDS professional is acting as a(n)
A portion of a deficiency slip is reproduced below. This patient was discharged yesterday. Your greatest concern regarding deficiencies on this record would be the missing
What type of plan is a Joint Commission-accredited facility required to maintain to protect health information from catastrophes such as fire, flooding, bomb threats, and theft?
A pharmacist at your facility was caught running a drug ring. The pharmacist filled orders of valuable medications with cheap outdated ones purchased on the Internet and then sold the good drugs for profit. Patients have been injured, and the lawsuits are starting. Unfortunately, your facility is going to be held responsible for the pharmacist's negligent acts under the doctrine of
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?
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
In an acute care hospital, a complete history and physical may not be required for a new admission when
a legible copy of a current H&P performed in the attending physician's office is available.
One of the patients at your physician group practice has asked for an electronic copy of her medical record. Your electronic computer system will not allow you to accommodate this request. Chances are, you are NOT in compliance with
meaningful use requirements.
In conducting an educational session for your staff about implementing a benchmarking program, you tell your staff that when an organization uses benchmarking, it is important to compare your facility's outcomes to
facilities with superior performance
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
Joint Commission does not approve 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.
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