Health Data Content and Standards Flashcards
Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that_____
evidences cannot be provided that the physician actually reviewed and approved each report.
As a concurrent record reviewer for an acute care facility, you hae asked Dr. Crossman to provide an updated hx and px 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:
A. A new H&P is required
B. apologize for not noticing this H&P
C: the H&P copy is acceptable as long as she documents any interval changes.
D. Joint Commission does not allow copies of any kind
C: the H&P copy is acceptable as long as she documents any interval changes.
As a working HIM professional, you are investigating the workforce development projections of EHR specialists as outlined by ARRA ad HITECH. In order to keep abreast of changes in this program, you will need to regularly access the Web site of this governmental agency:
ONC: Office of the National Coordinator for HIT. Federal Agency; charged with coordination of nationwide efforts to implement and use the most advance HIT and the electronic exchange of health information.
The first patient with cancer seen in your facility on January 1, 2015, was diagnosed with colon cancer with no known hx of previous malignancies. The accession number assigned to this patient is A. 15-0000/00 B. 15-0000/01 C. 15-0001/00 D. 15-0001/01
C. 15-0001/00
The final HITECH Omnibus Rule expanded some of HIPAA’s original requirements, including changes in immunization disclosures. As a result, where states require immunization records of a minor prior to admitting a student to a school, a covered entity is permitted to:
A. require written authorization from a custodial parent before disclosing immunization records.
B. all the minor to authorize the disclosures of immunization records.
C. Simply document a written or oral agreement from a parent or guardian before releasing the immunization record to the school.
D. refuse to disclose any information regarding child immunizations.
C. Simply document a written or oral agreement from a parent or guardian before releasing the immunization record to the school.
A recommendation for improvement from Joint Commission is indicated if the number of delinquent records is greater than __% or if the percentage of records with delinquent records due to missing H&Ps exceeds __% of the average monthly discharges. The percentage of incomplete records is ___ ________.
50; 2; not relevant.
Facilities that area scanning and imaging paper records as part of a computer-based system must give careful consideration to: A. Placement of hospital logo. B Signature line for authentication. C. Use of box design D. Bar Code Placement
D. Bar code placement
A data element you would expect to be collected in the MDS, but NOT on the UHDDS would be:
A. Personal identification
B. Cognitive Patterns
C. Procedures and dates.
D. Principal Diagnosis
B. Cognitive patterns
*The other answer choices represent items collected on Medicare inpatients according to UHDDS requirements. Only “cognitive patterns” represents a data item collected more typically in long-term care settings and required in the MDS.
When a patient is readmitted within __ days for the same or a related condition, an interval H&P may be completed if the original H&P is readily available.
30
Pt. presents to the ER in a coma. Her sister says the patient has had a recent medical history taken at the public health department. The physician on call can access this patient information using the area’s _____.
RIO
Regional Health Information Organization
The minimum length of time for retaining original medical records is primarily governed by:
state law
As part of a quality improvement study, you have been asked to provide information on the menstrual hx, number of pregnancies, and number of living children for each OB patient from a stack of old OB records. The best place to locate this information is the:
A. Prenatal record.
B. labor and delivery records
C. Postpartum Record
D. Discharge Summary
A: Prenatal record
(antepartum=prenatal) The antepartum (prenatal) record should include a comprehensive hx and px exam on each OB patient with particular attention to menstrual and reproductive hx.
Currently, the enforcement of HIPAA Privacy and Security Rules is the responsibility of
Office of Civil Rights
The 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:
Pathology report
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________ _________.
Federal Register
CMS publishes both proposed and final rules for the Conditions of Participation for hospitals in the daily Federal Register.