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CCA domain 3

Terms in this set (7)

The _______ provided the impetus for standardizing health care records with minimum standards early in the 20th century.


A. JCAHO
B. AHA
C. ACS
D. CMS
C. ACS The American College of Surgeons developed the minimum standards for hospital records in 1917.
The regulations for health care record content and documentation, guidelines and regulations for which facilities are allowed to take part in or join the Medicare and Medicaid programs is:

A. Medical Staff Bylaws
B. Conditions of Participation
C. Joint Commission Rules
D. American College of Surgeon's Regulations
B. CMS established the Conditions of Participation (CoP) which ae rules and regulations under which facilities are reviewed for medical necessity, compliance, and other decision making rules.
UHDDS
Uniform health discharge data set. Implemented in 1974 in an attempt to standardize data for billing and coding. Specific to hospitals that provide medical services for Medicare and Medicaid is standard practice for all insurance companies to gather information similar to that contained in the UHDDS. Required info could include: Hospital or facility id number, insurance payer number or code, sex, age, and race of the patient, significant medical procedures performed, principal diagnosis, additional significant diagnoses. Other information as required that effects healthcare.
quantitative analysis
Analyze medical records for any missing reports, forms, or required signatures and deletions.
Qualitative analysis
a review of the health record to ensure that standards are met and to determine the adequacy of entries documenting the quality of care
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?

A. Data completeness
B. Data relevancy
C. Data Currency
D. Data precision
C. data currency and data timeliness refer to the requirement that healthcare data should be up to date and recorded at or near the time of the event or observation.
MPI
Master Patient Index - index is used administratively for continuity of care and services as a "customer data base". Helps to determine if the patient has been seen in this facility before. Links a patient's medical record with common identification data elements.
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