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Health Data Content and Standards Practice Quiz 1 (RHIA/RHIT)
Terms in this set (25)
Discharge summary documentation must include
significant findings during hospitalization.
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
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?
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.
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.
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.
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?
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
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
Improving the specificity of clinical reports through the use of a physician query is a documentation goal that may be shared by the coding staff and this specialist:
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.
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
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.
Engaging patients and their families in health care decisions is one of the core objectives for
achieving meaningful use of EHRs
Ultimate responsibility for the quality and completion of entries in patient health records belongs to the
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
Under which of the following conditions can an original paper-based patient health record be physically removed from the hospital?
when the director of health records is acting in response to a subpoena duces tecum and takes the health record to court
The best example of point-of-care service and documentation is
nurses using bedside terminals to record vital signs.
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)
Which of the following services is LEAST likely to be provided by a facility accredited by CARF?
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.
Improving the clinical specificity of physician reports through a physician query is a goal shared by the coding staff and the
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 during resuscitation.
An example of a primary data source for health care statistics is the
Accreditation by Joint Commission is a voluntary activity for a facility, and it is
required for reimbursement of certain patient groups
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