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Health Data Content and Standards
Terms in this set (82)
In preparation for an EHR, you are conducting a total facility inventory for all form currently used. you much name each form for bar coding and indexing into a document management system. the unnamed doc in front of you includes a microscopic description of tissue excised during surgery. the doc type you are most likely to give to this form is
describes the surgical procedures. pre-op and post-op. and DX
In the past, JC 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.
For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the
Which includes patient care plans, pharm consultation, and transfer summaries are likelty to be found on the records of long-term care patients
What is an ambulatory care provider?
Patients don't spend the night, include walk in, urgent care clinics, doctors offices, clinics, outpatient hosipital visits
acute care service
Acute care services are generally delivered by teams of health care professionals from a range of medical and surgical specialties. Acute care may require a stay in a hospital emergency department, ambulatory surgery center, urgent care centre or other short-term stay facility, along with the assistance of diagnostic services, surgery, or follow-up outpatient care in the community. Hospital-based acute inpatient care typically has the goal of discharging patients as soon as they are deemed healthy and stable. Acute care settings include but are not limited to: emergency department, intensive care, coronary care, cardiology, neonatal intensive care, and many general areas where the patient could become acutely unwell and require stabilization and transfer to another higher dependency unit for further treatment.
The document that indicates current and past medical conditions
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 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
The H&P copy is acceptable as long as she documents an interval changes.
Discharge summary documentation must include
Significant findings during hospitalization.
Comprehensive outline of the patient's entire hospital stay; includes condition at time of admission, admitting diagnosis, test results, treatments and patient's response, final diagnosis, and follow-up plans
The performance of ongoing record reviews is an important tool in ensuring date quality. These reviews evaluate.
The overall quality of documentation in the record
The federally mandated resident assessment instrument used in long-term care facilities consist of three basic components, including the new care area assessment, utilization guidelines, and the___
Minimum Data Set (MDS) for Long-term care. The instrument specified by CMS that requires nursing facilities (both Medicare certified and/or Medicaid certified) to conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity
Care Area Assessment. (CCA)
long term care facility resident assessment that includes underlying causes, contributing factors, and risk factors for status decline.
The foundation for communicating all patient care goals in long-term care setting is the.
Interdisciplinary plan of care
As part of the JC'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
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.
A qualitative review of a health record reveals that the history and physical fora 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 JC standards.
The JC states that the H&P must be completed with 24 hours
Using the SOAP method of recording progress notes, which entry would most likely include a differential diagnosis?
A system of organizing information in a medical record. Subjective (symptoms of patient) data, Objective (exam findings) data, Assessment (evaluation of condition), Plan (goals for treatment).
You have been asked by a peer review committee to print a list of the medical record numbers of all patients who has CABG's performed in the past year at your acute care hospital. Which secondary data source could be used to quickly gather this information.
Coronary Arterial Bypass Graft
Many of the principles of form design apply to both paper based and computer-based systems. For ex, 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
Setting up a drop-down menu to make sure that the registration clerk collects "gender" as "male, female, unknown" is an example of ensuring data
refers to the accuracy of data, while
refers to consistency of date.
refers to data being available within a time frame helpful to the user, and
refers to data values that are just large enough to support the application of the process
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.
Medicare is federally funded.
CMS publishes both proposed and final rules for the Conditions of Participation for hospitals in the daily Federal Register.
Center for Medicare and Medicaid Services
A publication of the U.S. government that prints executive orders, rules, and regulations.
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 that was performed in the attending physician's office is available.
When can an Interval H&P be used?
When a patient is readmitted for the same of related problem with 30 days.
Uniform Hospital Discharge data Set (UHDDS) - A core set of data elements that is collected by hospitals on all discharges and all discharge abstract system
Gerda Smith was 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 dept. The physician on call is grateful that she can access this patient information using the area's
Regional Health Information Organization: also called a Health Information Exchange Organization, is a multi-stake holder organization created to facilitate HIE among stakeholders of that region's healthcare system. The ultimate objective is to improve the safety, quality, and efficiency of healthcare as well as access to healthcare through the efficient application of health information technology.
A system or organization in which people or groups are ranked one above the other according to status or authority
Electronic Document Management System
Represents a wide range of functionality, captures scanned images of documents, compile documents electronically fed from transcription systems, voice files from dictation, email and efax, integrated with workflow technology, allows veiwing from multiple locations and users
Computerized Physician Order Entry: application to enter patient care info and provides support tools which results in improved patient & outcomes
Also called knowledge based system; set of interactive computer programs that helps users solve problems that would otherwise require the assistance of a human expert. Expert systems are created on the basis of knowledge collected on specific topics from human specialists & they imitate the reasoning process of a human being.
You are the Director of Coding and Billing at a large group practice. The Practice Manager stops by your office on his way to a planning meeting to ask about the timeline for complying with HITECH requirements to adopt meaningful use EHR technology. You reply that the incentives began in 2011 and will end in 2014. you remind him that in 2015, sanctions for noncompliance will appear in the form of
Downward adjustments to Medicare reimbursement.
"Less money honey"
According to the following table, the most serious record delinquency problem occurred in which of the following months?
A recommendation for improvement from Joint Commission is indicated if the number of
delinquent records is greater than 50% or if the percentage of records with delinquent records due to missing H&Ps exceeds 2% of the average monthly discharges
In the month of April, both of these delinquency problems are reflected. The percentage of incomplete records is not relevant.
Ominibus Budget Reconciliation Act of 1987 laws that requires nursing centers to provide care in a manner or setting that IMPROVES a persons QUALITY of life, health and safety
Condition of Participation
You notice on the admission H&P that Mr. McKahn, 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 an__ will be added to his health record
COP requires a consultation report on patients who are not a good surgical risk as well as those with obscure diagnoses, patients whose physicians have doubts as to the best therapeutic measure to be taken, and pts for whom there is a question of criminal activity
You have been appointed a Chair of 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 JC 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.
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 has 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 know backlog exist, he should
Write a detailed operative note in the record.
JC requires that a detailed OP note be written in the health record when expeditious transcription of the dictated report is impossible to maintain continuity of care.
JC 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
An ex of a primary data source for health care stat is the
Primary data source
Refers to the record that was developed by healthcare professionals in the process of providing care.
Secondary data source
abstracted information; info taken from patient record and put into another form, ex: list, register, or index
Master Pt Index. Has the name of every pt receiving service at a facility (Pt's name, address, sex, DOB ID number, A&D dates, attending MD)
In the computerization of form, 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 types of review is this clerk performing?
Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart .
What is less likely to be identified by a deficiency analysis technician?
Discrepancy between post op DX by the surgeon and pathology DX by the pathologist.
Quality of Data documented.
Which of the following services is LEAST likely to be provided by a facility accredited by CARF
Chronic pain management
brain injury management
The Commission on Accreditation of Rehabilitation of Facilities is an independent accrediting agency for rehab facilities. Palliative care is most likely to be provided at a hospice not at a rehab center
Though you work in an integrated delivery network, not all systems in your network communicate with one another. as you meet with your partner organization, 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 that your organization join a
Regional health information organization
are intended to support health info exchange within a geographic region.
As a trauma registrar working in an emergency dept, you want to begin comparing your trauma care services to other hospital-based emergency dept. To ensure that your facility is collecting the same data as other facilities, you review elements from which data set?
DEEDS is used for?
Data Elements for Emergency Deparments- recommended data set for hosptal based emergency dept
UHDDS is used for?
Uniform Hospital Data Set- Required data set for acute care hospitals
MDS is used for?
Minimum Data Set- required data set for long term care fac
ORYX is used for?
An initiative of Joint Commission whereby five core measures are implemented to improve safety and quality of health care.
Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of.
Accreditation by the JC is a voluntary activity for a facility and its is
required for reimbursement of certain pt 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.
B/c info contained in the physicians index is considered confidential, identification codes are often used rather than the physicians names.
As a supervisor of the cancer registry, you report the 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 tech for your next committee meeting. you begin by googling
The American Recovery and Reinvestment Act was signed into law in 2009, and included significant funding for health information technology.
The information security officer is revising the policies at your rehab fac for handing all patient clinical information. The best resource for checking our specific voluntary accreditation standards and guidelines is the
Stage 1 of meaningful use focused on data capture and sharing. Which of the following is included in the menu set of objective for eligible hospitals in this stage.
Use of CPOE for medication orders
Computerized provider order entry. Enable a user to electronically record, change, and access the following order types, at a minimum:
(ii) Laboratory; and
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 mos
As a coding supervisor, your job description includes working with agents who have been charged with detecting and correcting over payments made to your hospital in the Medicare fee for Service program. You will need to develop a professional relationship with
Recovery audit contractors (RAC)
The RAC program is mandated to find and correct improper Medicare payments paid to heath care providers participating in the Medicare reimbursement program
Office of the Inspector General - safeguards health & wealthfare of Medicare/Medicaid beneficiaries & protect program integrity
Medicare Provider Analysis and Review (MEDPAR) A collection of data form reimbursement claims submitted to the Medicare program by acute care hospitals and skilled nursing facilities that is used to evaluate the quality and effectiveness of the care provided
Quality improvement organizations: external agencies that review the quality or care and use of insurance benefits by individual physicians and patients for Medicare and other insurers
In preparation for an upcoming site visit by JC, you discover that the number of delinquent records for the preceding month exceed 50% of discharged patients. Even more alarming was the pattern you notices 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
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
You want to review one doc in your fac that will spell out the doc requirements for patient records, designate the time 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.
What is the Joint Commission delinquency record rate?
Anything below this number is in compliance with the standards
One record documentation requirement shared by BOTH acute care and emergency departments is.
Patient's condition of discharge
As the Chair of the Form Committe are 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 explained that the review of systems is used to document.
Subjective symptoms that the patient may have forgotten to mention of 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 meeets
What is RAVEN software?
By Centers for Medicare and Medicaid Services (CMS). RAVEN is a computerized data entry system for long term care facilities that offers users the ability to collect Minimum Data Set (MDS) assessments in a database and transmit those assessments in CMS-standard format to your State database. The data entry software imports and exports data in standard MDS record format, maintains facility, resident, and employee information, enforces data integrity via rigorous edit checks, and provides comprehensive on-line help. It includes a data dictionary, RUGs and RAPs calculators, and your state section S form, if CMS has approved that form.
What is OASIS?
By Centers for Medicare and Medicaid Services (CMS). The Medicare Outcome and Assessment Information Set (OASIS) is used to measure patient outcomes. This site reports state and national mean values for all outcome measures included in the Outcome-Based Quality Improvement and Outcome-Based Quality Monitoring Reports that are available to home health providers from CMS.
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