Exam 2 Review

Question 1

WHAT DOES THE ACRONYM SOAP[E] STAND FOR?

Answer 1

S = subjective (what the patient says), we can not verify that it is true

O= objective (facts such as lab results, imaging results, physical exam findings)

A = assessment (conclusion drawn by physician)

P = plan

(Note nurses may add an ‘E’ for education given to patient.)

Question 2

WHAT ARE THE COMPONENTS OF THE PROBLEM ORIENTED MEDICAL RECORD (POMR)? 4 Answers

Answer 2

1. Problem list (all active and inactive problems with dates)
2. SOAP notes (progress notes that are integrated = all health care disciplines write their notes in the same location in the record)
3. Database (the collection of all the findings about the patient)
4. Discharge summary

Question 3

WHAT IS DIGITAL DICTATION

Answer 3

Provider dictates a report into a digital recording medium.
Transcriptionist listens to the report and types it for the health record.
Transcriptionist either:
- Uploads report to the electronic record
- Prints and files report in paper record
Provider reviews, changes as needed, and authenticates report.

Question 4

DISCHARGE SUMMARIES ARE REQUIRED FOR ALL PATIENTS EXCEPT: (3 answers)

Answer 4

Normal obstetric cases

Normal newborn cases

Patients who stay less than 48 hours and who have no complications.

Question 5

HOW LONG DOES THE PHYSICIAN HAVE TO COMPLETE THE DISCHARGE SUMMARY?

Answer 5

Joint Commission says:
30 days from the date of discharge

Question 6

IF THE PATIENT IS BEING TRANSFERRED TO ANOTHER FACILITY, HOW LONG DOES THE PHYSICIAN HAVE TO COMPLETE THE TRANSFER SUMMARY?

Answer 6

Joint Commission says:
1. It must be ready to go with the patient so it must be done by the date the patient transfers.

2. It is the same as a discharge summary.

Question 7

INCOMPLETE VS. DELINQUENT RECORDS ACCORDING TO JOINT COMMISSION ARE

Answer 7

1. Incomplete: Deficiencies but still less than or equal to 30 days from discharge
2. Delinquent records: Deficiencies and more than 30 days from discharge

Question 8

WHAT IS CONCURRENT REVIEW?

Answer 8

Checking the record for deficiencies while the patient is still in the hospital

HIM staff go to the nursing units to review records

Question 9

WHAT ARE HYBRID RECORDS?

Answer 9

Some parts on paper. Some parts electronic.

Parts on paper (or scanned paper documents): information is not searchable/retrievable by computer.

Question 10

WHAT IS UNIT NUMBERING?

Answer 10

Assigns a number to each patient that will be used each time the patient returns for care.

The patient will have one number for life.

Question 11

WHAT IS A SERIAL NUMBERING SYSTEM?

Answer 11

Gives the patient a new number each time the patient returns to the hospital for care.

Question 12

WHAT IS QUANTITATIVE ANALYSIS?

Answer 12

Also called deficiency analysis

Looking for the presence or absences of required reports and signatures in the record.

Done on all records

We refer to signatures as authentications. When the physician signs a report, he/she assumes responsibility for the content of the report.

Question 13

WHAT IS QUALITATIVE ANALYSIS?

Answer 13

Looking at the quality of the documentation in the record:

Does each report contain all the required elements that are recommended by the licensing/accrediting/certifying organizations?

Does the record reflect good clinical practice according to published guidelines?

Not done on all records. Done on a sample of records.

Question 14

WHAT IS THE MPI? And what do we use it for?

Answer 14

Master Patient Index

Used to look up a patient’s name(s) and determine if the patient has ever been in the facility.

Used to find/assign the medical record number.

Used to look up a medical record number and find the patient associated with it.

Question 15

WHAT IS THE EMPI?

Answer 15

An Enterprise Master Patient Index.

A master patient index that is shared among several facilities in a health care network.

Question 16

WHAT IS THE DIFFERENCE BETWEEN AN ESIGNATURE AND A DIGITAL SIGNATURE?

Answer 16

Esignature – uses login/password to verify identity of physician, physician clicks on a button to sign a document

Digital signature – physician writes his/her name on a signature machine attached to the computer (similar to what is used in stores for some credit card/debit card purchases or for pick-up of prescriptions). Gives a picture of the signature.

Question 17

WHAT IS A SUSPENSION POLICY?

Answer 17

Temporarily withdrawing a physician’s ability to admit patients to the hospital, or temporarily withdrawing a surgeon’s ability to schedule elective surgery.

Due to incomplete records. In this surgeon’s case, this may be missing operative reports.

Policy approved by the Medical Staff. Authority given to the Health Information Manager to invoke the suspension and to lift the suspension when the records are complete.

Question 18

WHAT DOES THE NEW YORK STATE EDUCATION LAW SAY ABOUT MEDICAL PROFESSIONALS WHO DO NOT MAINTAIN APPROPRIATE PATIENT RECORDS?

Answer 18

They have committed unprofessional conduct.

(Some medical professionals have lost their license to practice for this reason.)

Question 19

WHAT ARE THE COMPONENTS OF AN INFORMED CONSENT FOR SURGERY? (5 Answers)

Answer 19

1. Diagnosis requiring the procedure – explain to the patient in lay terms
2. Name of the procedure – use lay terms
3. Benefits - what good should be achieved from the procedure
4. Risks – what could go wrong and the chances of a risk
5. Consequences – what will happen as a result of the procedure

Question 20

WHAT ARE THE TIMING REQUIREMENTS FOR THE OPERATIVE REPORT?

Answer 20

Immediately after surgery
Add a surgical progress note if there will be a transcription delay.

Question 21

WILL THERE BE A PATHOLOGY REPORT FOR ALL SURGERIES?

Answer 21

No.
A pathology report is only done if something is removed during surgery:
- Tissue
- Foreign body such as a splinter or a bullet. The microscopic exam is not done on a foreign body.

Question 22

WHAT IS DIFFERENT ABOUT THE DISCHARGE SUMMARY REQUIREMENTS FOR OBSTETRIC CASES AND FOR NEWBORNS?

Answer 22

A discharge summary is not needed for normal cases.