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Health Data Content- CCA Prep
Terms in this set (40)
Use of prohibited or dangerous abbreviations.
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
For continuity of care, ambulatory care providers are more likely than providers of acute Care services to rely on the documentation found in the
Joint Commission does not approve of 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.
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 any interval changes.
Ultimate responsibility for the quality and completion of entries in patient health records belongs to the
As part of joint Commission'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
According to the joint Commission's national patient safety goals, which of the following abbreviations would most likely be prohibited
.4 mg Lasix
Using the SOAP method of recording progress notes, which entry would most likely include a differential diagnosis?
In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for certification standards is the
In an acute Care hospital, a complete history and physical may not required for new admission when
A legible copy of a recent H&P performed in the attending physician's office is available
When developing a data collection system, the most effective approach first considers
The end user's needs
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 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
Before you submit a new form to the Forms Review Committee, you need to track the field name of a particular data field and the security levels applicable to that field. Your best source for this information would be the
Facility's data dictionary
You notice on the admission H&P that Mr Mack, a medicare patient, was admitted for disc surgery, but the progress notes indicate that due to some heart irregularities, he may not a (n)-------will be added to his health record.
You have 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 joint Commission 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
An example of a primary data source for health care statistics is the
During a retrospective review of Hunter's inpatient health record, the health information clerk notes that on day 4 of hospitalization there was one missed dose odd insulin. What type of review is this clerk performing?
In your facility, the health care providers from every discipline document progress notes sequentially on the same form. Your facility is utilizing
Integrated progress notes
Which of the following services is least likely to be provided by a faculty accredited by CARF?
Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example
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?
Which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record?
You have been asked to report the registry's annual caseload to administration. The most efficient way to retrieve this information would be to use
The best resource for checking out specific voluntary accreditation standards and guidelines for a rehabilitation facility is the
Stage 1 of meaningful use focuses on data capture and sharing. Which of the following in included in the menu set of objectives for eligible hospitals in this stage?
Use CPOE for medication orders
Which of the following is a secondary data source that would be used to quickly gather the health records of juvenile patients treated for diabetes within the past 6 months?
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 recommend that staff routinely check to verify that a summary on each patient is provided to the attending physician so that her or she can review, update, and recertify the patient as appropriate. The time frame for requiring this summary is at least every
You want to review the one document in your facility that will spell out the documentation requirements for patient records designate the time frame 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
When asked to explain how"review of systems" differs from "physical exam" you explain that the review of systems is used to document
Subjective symptoms that the patient may have forgotten to mention our that may have seemed unimportant
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
An example of a primary data source is the
The recovery audit contractor (RAC) program identifies improper payments for
Collection of overpayments
You have been asked to give an example of a clinical information system. Which one of the following would you cite?
Laboratory information system
The PQRS is a reporting system established by the federal government for physician practices that participate in Medicare
Quality measure reporting
Surgical case review includes all except
Cases with serious surgical complications or surgical mortalities
While performing routine quantitative analysis of a record, a medical record employee finds an incident report in the record. The employee brings this to the attention of her supervisor. Which best practice should the supervisor follow to deal with this situation?
Remove the incident report and send it to the patient
In compelling statistics to report the specific cause of death for all open-heart surgery cases, the quality coordinator assists in documenting
Patient care outcomes
The utilization review coordinator reviews inpatient records at regular intervals to justify necessity and appropriateness of care to warrant further hospitalization. Which of the following utilization review activities is being performed?
Continued stay review
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