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RHIT 2019 Reviewer Domain 1

Terms in this set (202)

UHDDS: Uniform Hospital Discharge Data Set
a health record technician has been asked to review the discharged patient abstracting module of a proposed new EHR. Which of the following data sets would the technician consult to ensure the system collects all federally required discharge datra elements for Medicare and Medicaid inpatients in an acute-care hospital?
Vocabulary standards
Standardizing medical terminology to avoid differences in naming various health conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallux valgus) is one purpose of?
Evaluate patterns and trends of patient care
Patient care managers use the data documents in the health record to
Data consistency
At admission Mrs. Smith's date of birth is recorded as 3/25/2948. An audit of the EHR discovers that the numbers in the date of birth are transposed in reports. This situation reflects a problem in
Vital Sign Record
A health data analyst has been asked to compile a listing of daily blood pressure readings for patients with a diagnosis of hypertension who were treated on the medical unit within a two-week period. What clinical report would be the best source to gather this information?
use an itemized list of the patient's pas and present health problems
Which of the following is a key characteristic of the problem-oriented health record?
The disease to be reported are established by state law
Which of the following is true regarding the reporting of communicable disease?
Identify data content requirements for all areas of the organization
A new HIM director has been asked by the hospital CIO to ensure data content standards are identified, understood, implemented, and managed for the hospital's planned EHR system. Which of the following should be the HIM director's first step in carrying out this responsibility?
Medication administration record and clinical laboratory reports
A health data analyst has been asked to compile a report of the percentage of patients who had a baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical reports in the health record would the data analyst need to consult in order to prepare this report.
Master Patient Index (MPI)
Which of the following is considered the authoritative key in locating a health record
Data map
The HIM manager is conducting a study in which she is comparing the current's year's diagnosis codes to the proposed new codes for the next fiscal year and documenting variations in order to assess the impact on the organization. This process creates a
Consultation
A family practitioner requests the opinion of a physician specialist who reviews the patient's health record and examines the patient. The physician specialist would record findings, impressions, and recommendations in what type of report.
Laboratory
The MPI manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. After spending time merging the patient information and correcting the duplicates in the patient information system, the MPI manager needs to notify which department to correct the source system data
UACDS (Uniform Ambulatory Care Data Set)
An outpatient clinic is reviewing the functionality is considering for purchase. Which of the following data sets should the clinic consult to ensure that all the federally recommended data elements for Medicare and Medicaid outpatients are collected by the system?
Review each patient's health record concurrently to make sure that history and physicals are present
To comply with the Joint Commission standards, the HIM director wants to be sure that history and physical examination are documented in the patient's health record no later than 24 hours after admission. Which of the following would be the best way to ensure the completeness of the health record?
Consult with the physician in charge of the on-call doctors for suggestions on how to improve response to the current notices
The HIM director is having difficulty with the emergency services on-call physicians completing their health records. Three deficiency notices are sent to the physicians including an initial notice, a second reminder, and a final notification. Which of the following would be the best first step in trying to rectify the current situation.
Conditions of Participation
Valley High, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to become certified for those programs?
Delinquent Record
A health record with deficiencies that are not completed within the timeframe specified in the medical staff rules and regulations in called
To determine whether standards of care are being met
How do accreditation organizations such as the Joint Commission use the health record?
Outcomes and Assessment Information Set
Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers
Licensure
Before healthcare organizations can provide services, they usually must obtain ____ by government entities such as the state or country in which they are located
The template was defined
The following descriptors about the data element ADMISSION_DATE have included in a data dictionary: definition: date patient admitted to the hospital; data type: date; field length: 15; required field: yes; default value: none; template: none. For this data element, data integrity would be better assured if
drop-down menu
In designing an input screen for an EHR, which of the following would be best to capture structured data?
Develop a list of statues, regulations, rules, and guidelines that contain requirements affecting the release of health records
A medical group practice has contracted with an HIM professional to help define the practices legal health record. Which of the following should the HIM professional perform first to identify the components of the legal health record?
By the hospital
Hospital physical documents relating to the delivery of patient are such as health records, x-rays, laboratory reports, and consultation reports are owned
Standard
Which of the terms below represents fixed rules that must be followed?
Support for reserarch
Which of the following is a secondary purpose of the health record?
The legal health record may contain metadata
Which of the following is a true statement about the content of the legal health record?
Ease of entry
The advent of the EHR has increased the amount of documentation largely due to
Provides oversight for the development, review, and control of forms and computer screens
The forms design committee
overlay
Two patients records were filed together by mistake. This is an example of
obliterating or deleting errors
Erin is an HIM professional, She is teaching a class to clinicians about proper documentation in the health record. Which of the following is an example of improper teaching?
Copying the note in the wrong patient's record
Which of the following is a risk of copy and pasting?
medical history
Which of the following is the health record component that addresses the patient's current complaints and symptoms and lists that patient's past medical, personal, and family history
assigning the health record number
The patient registration department assists the HIM department in what way?
It is the record disclosed upon request
Which of the following is characteristics of the legal health record?
DEEDS
A data sets would be most helpful in developing a hospital trauma data registry?
A disease index
Dr. Jones comes into the HIM department and requests that the HIM director provides a list of his records from the previous year that shows a principal diagnosis of myocardial infarction. What would the HIM director use to provide this list?
91.3%
Community Hospital's HIM department conducted a random sample of 150 inpatient health records to determine the discharge summary completion timeliness rate. Thirteen discharge was determined to be out of compliance with completion standards. Which of the following percentages represents the timeliness rate for discharge summaries at Community Hospital?
OASIS-C
Activities of daily living (ADL) are components of
consent for operative procedure, history, physical examination
documentation that must be included in patient's health record prior to performing a surgical procedure
Shading of bars or lines that
This should be avoided when designing forms for an electronic document management system (EDMS)

a. color borders around the edge of a form
b. mnemonic descriptor used for nonbarcode recognition engine
c. quarter inches border on each side of document without bar code
d. sharing of bars or lines that contain text
permanently
AHIMA's retention standards recommend that the master patient index be maintained

a. for at least 5 years
b for at least 10 years
c. for at least 25 years
d. permanently
data precision
a type of specificity that defines the expected values of the gender data element as female, male, and unknown.
voluntarily or by state law
Cancer registries are maintained by hospitals
operative report
reports that include names of the surgeon and assistants, date, duration and description of the procedure and any specimens removed
digitally scan all paper records post discharge, and integrate and index these into the existing electronic document management system
The hospital currently has a hybrid health record. Nurses and clinicians are recording bedside documentation electronically in a clinical documentation system. while most other documentation, such as physician progress notes and orders, are paper, based and stored in a paper health record, making retrieval of the complete record after discharge difficult and risking the records' integrity. Given these circumstances, which of the following should the HIM director implement to alleviate these problems and preserve the efficiencies of an electronic record?
request that the physician dictate an addendum to the discharge summary
In a routine health record quantitative analysis review, it was found that a physician dictated a discharge summary on 1/26/20xx. Because of unexpected complications, however, the patient was discharge two days after the discharge summary was dictated. What would be the best course of action in this case?

a. request that the physician dictate an addendum to the discharge summary
b. have the record analyst note the date discrepancy
c. request that the physician dictate another discharge summary
d. file the record as complete because the discharge summary includes all of the pertinent patient information
inform the committee that according to the Conditions of Participation , all documentation must include date and time
The hospital is revising its policy on health record documentation. currently, all entries in the health record must be legible, complete, dated and signed. The committee chairperson wants to add all entries must have the time noted. However, another clinician suggests that adding the time of notation is difficult and rarely may be correct because personal watches and the hospital clocks may not be coordinated. Another committee member agrees and says that only electronic documentation needs a time stamp. Given this discussion, which of the following might the HIM director suggest?

a. suggest that only hospital clock time be noted in clinical documentation.
suggest that only electronic documentation haeve time noted
c. inform the committee that according to the Conditions of Participation, all documentation must include the date and time
inform the committee that according to the Conditions of Participation, only medication order must include data and time
physical examination
identify the report where the following information would be found: "HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds

a. discharge summary
b. health history
c. medical lab report
d. physical examination
aggregate data
You are the director of HIM at Community Hospital. A physician has asked for the total number of appendectomies that he performed at your hospital last year. What type of data will you provide the physician with?

a. patient-specific data
b. aggregate data
c. operating room data
d. nothing - you cannot obtain this data after the fact
make all essential data fields required
the best technique to ensure nurses do not omit any essential information on the nursing intake assessment in EHR
data elements
patient name, zip code, and health record number are typical

a data elements
b. data sources
c. aggregate data
d. data monitors
MPI Master Patient Index
The link that tracks patient, person, or member activity within healthcare organization and across patient care settings is known as
provide a template for entering data in the field
which of the following would be the best technique to ensure that registration clerks consistently use the correct notation for assigning admission data in an EHR

a. make admission date a required field
b. provide a template for entering data in the filed
c. make admission data a numeric field
d. provide sufficient space for input of data
demographic data
what is the information identifying the patient (such as name, health record number, address, and telephone) called?
data dictionary
managing an organization data and those who enter it is an ongoing challenge requiring active administration adn oversight. This can be accomplished by the organzation through managmenet of which of the following?

a. data dictionary
b. data warehouse
c. data mapping
d. data set
data element
in a database, the LAST_NAME column in a table would be considered a
edit checks
a coding analyst consistently enters the wrong code for patient gender in the computer billing system. What measure should be in place to minimize this data entry error?
consistency
two coders have found the same abbreviation on two records. One abbreviation of "O.D" was used on an eye health record to mean right eye. The other abbreviation on another patient's records was used to mean overdose on an abuse record. What data quality component is lacking here?

a. timeliness
b. completeness
c. security
d. consistency
Identifying deficiencies early so they can be corrected
the goal of the quantitative analysis performed by HIM professional?

a. ensuring that the health record is legible
b. verifying that the health professionals are providing appropriate care
c. identifying deficiencies early so they can be corrected
d. ensuring bills are correct
Medical staff bylaws
The credentialing process of independent practitioners within a healthcare organization must be defined in
Wil be disclosed upon request
The legal health records

is inadmissible into evidence
may not be hybrid
must consist in part on paper
will be disclosed upon request
Patient's advance directive
Physician orders for DNR and DNI should be consistent with

Patients advance directive
Patient's bill of rights
Notice of privacy practices
Authorization for release of information
Inability to identify the author
Which of the following is an argument against the use of the copy and paste functions in the HER

Inability to identify the author
Inability to print the data out
The tie that it takes to copy and paste the documentation
The users will not know how to perform the copy and paste function
The amendment must have a separate signature, date and time
How are amendments handled in the EHR?

Amendments are automatically appended to the original note. NO additional signature is required.
Amendments must be entered by the same person as the original note.
Amendments cannot be entered after 24 hours of the event.
The amended must have a separate signature, date and time
A third part payer
An institutional user of the health record
Policies and procedures to control which versions displayed
Version control of documents in the HER requires

The deletion of old version and the retention of the most recent one
Policies and procedures to control which version is displayed
Signed and unsigned documents not to be considered two versions
Pervious version to be accessible to administration only
Administrative data
A patient's gender, phone number, address, net of kin, and insurance policy holder information would be considered what kind of data?
Accountability and integrity
Components of AHIMA's principles of information governance
Information considered to add value to an organization
Information assets are:

Information considered to add value to an organization
Data entered into a patient's health record by a provider
Clearly defined elements required to be documented in the health record
A list of data elements added within record
Assuring documentation that is being changed is permanently deleted from the record
Which of the following is not a recommended guideline for maintaining integrity in the health record?

Specifying consequences for the falsification of information
Requiring periodic training covering the falsification of information and information security
Assuring documentation that is being changed is permanently deleted from the record
Prohibiting the entry of false information into any of the organization's records
a. Provide uniform data definitions
In healthcare, data sets serve two purposes- The first is to identify data elements to be collected about each patient. The second is to:
UHDDS
A health information technician is responsible for designing a data collection form to collect data on patients in an acute-care hospital. The first resource that she should use is:
d. Data dictionary
A critical early step in designing an. EHR is to develop a(n) _ in which the characteristics of each data element are defined.
MDS
In a long-term care, the resident's care plan is based on data collected in the:
b. They provide a complete and exhaustive list of data elements that must be collected.
Which of the following is not a characteristic of the common healthcare data sets such as UMLDDS and UACDS
d. Integrity
What is the term that is used to mean ensuring that data are not altered during transmission across a network or during storage
a. Recommend common data elements to be collected in health records
The primary purpose of a minimum data set in healthcare is to:
a. Subjective
A notation for a diabetic patient in a physician progress note reads: "Occasionally gets hungry- No insulin reaction She says she is following her diabetic diet," In which part of a problem- oriented health record progress note would this be written?
b. Granularity
An audit of a hospital's electronic health system shows that diagnostic codes are not being reported at the correct level of detail. This indicates a problem with data:
. In a study comparing the incidence of myocardial infarctions in black males as compared to white females
In which of the following examples does the gender of the patient constitute information rather than) a data element?
b. Continuity of care record
11. A core data set developed by ASTM to communicate a patient's past and current health information as the patient transitions from^ care setting to another is:
b. OASIS-C
12. The home health prospective payment system uses the data set for patient assessments.
a. Assessment
13. A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled." " In which part of a problem-oriented health record progress note would this be written')
d. Systematized Nomenclature of Medicine Clinical Terminology
14. Which of the following provides a standardized vocabulary for facilitating the development of computer-based patient records?
d. HEDIS
15. The data set designed to organize data for public release about the outcomes of care is:
b. Data consistency
16- Mrs. Smith's admitting data indicates that her birth date is March 21,1948. On the discharge summary, Smith's birth date is recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record?
. Operative report
17. Identify where the following information would be found in the acute-care record: "Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion."
Structure and content
18. What type of standards provide clear descriptors of data- element to be included in computer-based patient record systems?
d. Data accountability
19. Which of the following is not a characteristic of high-quality healthcare data?
b. Data are easy to obtain
20. Which of the following is a primary purpose of the health record?
b. Data are easy to obtain
21. Which of the following best describes data accessibility
c. Invoice for services
22. Which of the following elements is not a component of most patient health records?
a. Laboratory report
23. Identify where the Moving documentation would be found in the acute-care record: "CBC: WBC 12.0, RBC 4.65, HGB14.8, HCT 43.3, MCV 93."
b. Discharge summary
24. The attending physician is responsible for which of the following types of acute-care documentation?
A numerical measurement carried out to the appropriate decimal place
25. Which of the following represents an example of data granularity?
Admitting diagnosis
26. Which of the following is an example of clinical data
c. Data currency
27. Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missing from the progress note?
b. Patient registration
28. In which department or unit is the health record number typically assigned?
d. Social service note
29. The following is documented in an acute-care record: "Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CpS re: referral. Case manager to meet with patient and family" In which of the following would this documentation appear
c. Data include all required elements.
30. Which of the following best describes data comprehensiveness
b. In numeric order
On the problem list in a problem-oriented health record, problems are organized:
Medical history
.Which of the following represents documentation of the patient's current and past health status?
Medication administration record
A nurse is responsible for which of the following types of acute-care documentation?
Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care
What is the function of a consultation report
research
A secondary purpose of the health record is to provide support for which of the following?
d. physical examination
The following is documented in an acute-care record: "HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma. CHBST: Good bilateral chest sounds." In which of the following would this documentation appear?
ECG report
The following is documented in an acute-care record: "Atrial fibrillation with rapid ventricular response, left axis deviation, left bundle branch block:." In which of the following would this documentation appear?
Concurrent scanning
The HIM department is planning to scan paper-based components of the medical record such as consent forms and lab orders from physician offices. Which of the following methods would be best to help HIM professionals monitor the completeness of health records during a patient's hospitalization?
Reliability
Two health information professionals are abstracting data for the same case for a registry- When their work is checked, discrepancies are found. Which data quality component is lacking?
patient's complete medical history
Which of the following materials is not documented in an emergency care record?
c. Disease
Which one of the following indexes contains a list maintained in diagnosis code number order for patients who are discharged from a facility during a particular time period?
American College of Surgeons
Cancer registries receive approval as part of the facility cancer program from which of the following agencies?
Inpatients receive room, board, and continuous nursing services in areas of the hospital where patients generally stay overnight; outpatients receive ambulatory diagnostic and therapeutic services.
Which of the following statements best describes the difference between a hospital inpatient and a hospital outpatient?
Operation
Which one of the following indexes contains a list maintained in procedure code number order for patients who are discharged from a facility during a particular time period?
b. Registration
HIM departments may be the hub of identifying^ mitigating, and correcting MPI errors, but that information often is not shared with other departments within the healthcare organization. After identifying procedural problems that contribute to the creation of the MPI errors, which department should the MPI manager work with to correct these procedural problems?
Coding and billing staff
Which of the following is an individual user of the health record?
Present this information at the next medical staff meeting to inform physicians on documentation standards and guidelines.
The coding manager at Community Hospital is seeing an increased number of physicians failing to document the cause and effect of diabetes and its manifestations. Which of the following will provide the most comprehensive solution to handle this documentation issue?
b. Validity
Which of the following elements of coding quality represent the degree to which codes accurately reflect the patient's diagnoses and procedures?
Outcome
OASIS-C data are used to assess the ——— of home health services.
. Accreditation
The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards is called:
The Joint Commission
Which of the following has been responsible for accrediting healthcare organizations since the mid-1950s and determines whether the organization is continually monitoring and improving the quality of care provided?
Clinical forms committee
What committee usually oversees the development and approval of new forms for the health record?
Uses radio buttons to select multiple items from a set of options
Which of the following is not true of good electronic forms design?
Insurance companies that cover healthcare expenses
Insurance companies that cover healthcare expenses
Care plan
Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps?
Twice
How many times each year are healthcare facilities required to practice emergency preparedness plans?
Commission on Accreditation of Rehabilitation Facilities
This private, not-for-profit organization is committed to developing and maintaining practical, customer-focused standards to help organizations measure and improve the quality* value, and outcomes of behavioral health and medical rehabilitation programs.
Data dictionary
Multiple users entering data may have different definitions or perceptions about what goes into a data field, thereby confounding the data. For example, one department may use the term "PATIENT" while another department my use the term "CLIENT' to define the same entity. Which of the following would be used to provide standardization?
The Joint Commission
Which accrediting organization has instituted continuous improvement and sentinel event monitoring and uses tracer methodology during survey visits?
Version control is easy to implement.
Which of the following is not a true statement about a hybrid health record system?
Interoperability
The ability to electronically send data from one EHR to another while maintaining the original meaning is called:
Identity matching algorithm
What is the key piece of data needed to link a patient who is seen in a variety of care settings*
Conditions of Participate
What is the general name for Medicare rules affecting healthcare organizations?
Controlled vocabulary
Which of the following is necessary to ensure that each term used in an EHR has a common meaning to all users?
Ensures that appropriate data are collected timely
Why does an ideal EHR system require point-of-care charting?
Input mask
When a user keys in 10X01963, the computer displays it as 10/10/1963. What enables this?
Electronic document management system
A transition technology used by many hospitals to increase access to health record content is:
Design a plan
What is the first step an organization should take when developing a data dictionary?
Elements of performance
Specific performance expectations and structures and processes that provide detailed information for each of the Joint Commission standards are called:
Comprehensiveness
When all required data elements are included in the health record, the quality characteristic for data is met.
Completeness
A record that fails quantitative analysis is missing the quality criterion of:
HEDIS
This data set was developed by the National Committee for Quality Assurance to aid consumers with health-related issues with information to compare performance of clinical measures for health plans:
Credential
What is the status conferred by a national professional organization that is dedicated to a specific area of healthcare practice*)
Qualitative analysis
Joan reviewed the health record of Sally Williams and found the physician stated on her post—op note, "examined after surgery." This review process would be an example of:
Document name, media type, source system electronic storage start date, stop printing start date
Which of the following data sets would be most useful in developing a grid for identification of components of the legal health record in a hybrid record environment?
Establishment of its baseline trustworthiness
Authentication of a record refers to:
Establish minimum quality standards for hospitals
The primary goal of the Hospital Standardization Program, established in 191 8 by the American College of Surgeons, was to:
The field type should be changed to Character.
The following descriptors about the data element PATIENTLAST_NAME are included in a data dictionary: definition: legal surname of the patient; field type: numeric; field length: 50; required field: yes; default value: none; input mask: none. Which of the following is true about the definition of this data element?
The Joint Commission
...
All categories of health records
General documentation guidelines apply to:
Behavioral health records
What type of health records may contain family and caregiver input?
The content may contain outdated information
Why should the copy and paste function not be used in the electronic health records
Long-term care
. An RAI/MDS and care plan are found in records of patients in what setting
Data stewardship
The evaluation of data collected based on business needs and strategy is part of
Element
A patient's birth date and gender documented in the health record are examples of a data
Tracer methodology
Which Joint Commission survey methodology involves an evaluation that follows the hospital experiences of past or current patients?
Quantitative analysis
George reviewed the patient record of Mr. Brown and found there was no H&P on the record at seven hours past this patient's admission time. This review process would be an example of:
Is the number assigned to each case as it is entered into a cancer registry
In a cancer registry, the accession number:
Patient-identifiable
Bob Smith is a 56-year-old white male. This is an example of what type of data?
Master patient index
Which of the following indexes is an important source of patient health record numbers
Demographic data
What are the patient data such as name, age, and address called?
Trauma registry
What type of registry maintains a database on patients injured by an external physical force
Information
Which of the following are data that have been filtered and put into context?
Meaningful use
Which of the following describe criteria with specific objectives and measures that hospitals must meet to demonstrate they are using EHRs that positively affect patient care?
c. MPI
Which of the following systems is the key to identifying a patient's multiple hospitalizations?
Data governance
Which of the following Enterprise Information Management (EIM) functions is the overarching authority for managing an organization's data assets?
. Embedded metadata
Which of the following would be used to track data movement from one system to another?
Constraint
The statement, "the unique patient identifier must be numeric," is an example of which of the following business rule categories?
. Linking an older version of a code set to a newer version
Which of the following is the best definition of a forward map in data mapping?
Data steward
Which of the following individuals would serve as a bridge between information technology and business and clinical areas while managing each key area?
Data integrity
The patient's address is the same in the master patient index, electronic health record, laboratory information system, and other systems. This means that the data values are consist". consistent and therefore indicative of which of the following?
Information governance
The term used to describe controlling information is
a. Evaluate the performance of employees
How do patient care managers use the data documented in the health record?
Comprehensiveness
Which of the following data quality characteristics means all data items are included within the information collected?
Assuring documentation that is being changed is permanently deleted from the record
Which of the following is not a recommended guideline for maintaining integrity in the health record?
The documentation needs based on accrediting bodies
When creating requirements of documentation for the hospital bylaws, which of the? following should be evaluated?
The use of the health record by a clinician to facilitate quality patient care is considered:
The use of the health record by a clinician to facilitate quality patient care is considered:
CARF
. Which group focuses on accreditation of rehabilitation programs and service^
Deemed status
What is it called when accrediting bodies, such as the Joint Commission, rather than the government can survey facilities for compliance with the Medicare Conditions of Participation for Hospitals?
Mary Jones's hemoglobin of 13 is within normal range
Which of the following statements represents knowledge?
Data silos and fragmented data inhibit data integration
Which of the following is the best example of a data governance business case?
Laboratory findings
Results of a urinalysis and all blood tests performed would be found in what part of a healthcare record?
Restricting use of abbreviations to a list approved by hospital and medical staff bylaws, ru]es, and regulations
Which of the following is considered a clinical documentation best practice?
The H&P must be documented within 30 days before admission with an update within 24 hours after admission
Dr. Hall is an orthopedic surgeon performing a knee replacement on Mary- Mary was seen in Hall's office 2 months before the surgery and Dr. Hall documented her history and physical (H&P) at that point. Does his H& P meet documentation requirements for the surgery?
Purged
At the time a hospital implemented an electronic health record, the the Health Record Committee determined that all records of patients who have not been treated at the facility in the past two the active filing area. These patient records are considered from. the active filing area,
Permanently
How long should the MPI be retained?
Long-term care
a patient's registration forms, personal property list, RAL care plan, and discharge or transfer documentation would be found most frequently in which type of health record1)
Emergency care
Which type of health record contains information about the means by which the patient arrived at the healthcare setting and documentation of care provided to stabilize the patient?
Electronic point-of-care charting
Electronic systems used by nurses and physicians to document assessments and findings are called:
Promoting the sale of enterprise data
Which of the following is not part of data governance
To determine whether standards are being met
How do accreditation organizations use the health record*)
This is an example of reverse mapping
A healthcare system wants to map ICD-10-CM to ICD-9'CM. Which of the following would be true about this effort?
Reduce documentation variability
What is the primary puipose of structured data entry
Cancer-registry
Which of the following is considered a secondary data source?
Date of birth
Which of the following would be a discriminating attribute used to disqualify two or more similar records?
When one entity has different unique identifiers in different databases
In data matching which of the following best describes an overlap?
Authoritative source for data about an entity
Which of the following is the best definition of system of record (SOR)?
The average length of stay is the sum of inpatient days for a period divided by the Member of discharges for a period
Which of the following would be considered a derivation business rule?
Describes a real or conceptual structure that organizes a system or concept
Which of the following is the best definition of a data governance framework;?
Including original and revised dates
Which of the following should be taken into consideration when designing a health record form?
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