Medical records Flashcards
What does MDS stand for?
Minimum data set
What is UHDDS?
Uniform Hospital discharge data set
What type of facility uses MDS?
Long-term care
When type of patient is UHDDS collected from?
Hospital inpatients
What type of information is collected as part of that UHDDS?
Personal identification, procedures and dates, principal diagnosis,date of birth, sex, race, discharge date, external cause of injury
What are some data elements of MDS?
Demographics, daily activities, mood and behavior, therapies, special treatments and procedures, or nutrition dental status, medications and discharge information
Describe auto authentication:
Policy adopted by something that allow physicians to stay in advance the transcribed reports should automatically be considered approved and signed when the physician fails to make corrections within the allotted time.
Why are auto authentication policies problematic?
They do not ensure that the physician has reviewed and approved each report
When may a physician include a copy of the history and physical?
When a patient has been readmitted within 30 days for the same or related problem or
Or a recent H&P has been done in the doctors office and any interval changes have a document
Abbreviations are prohibited by what government organization?
The joint commission
What is an interdisciplinary care plan?
Goals for patient care
What is the number index?
It identifies new health record numbers and the patients to whom they were assigned
What is the physicians index?
It identifies all patients treated by each doc
What is the disease index?
Identify patients by the disease assigned
What information must be included in the discharge summary?
Significant findings during hospitalization
Who is responsible for recording the discharge summary?
The attending physician
What does qualitative analysis review?
The overall quality and consistency, of documentation
Eg comparing the pharmacy drug profile with the MAR
Who is ultimately responsible for the quality and completion of entries in the patient health record?
The attending physician
True or false: in an acute care setting most healthcare practitioners document separately
True this is different from a long-term care organization
In a long-term care facility what is the foundation around which patient care is organized?
The patient care plan
What are the joint commission requirements for marking a surgical site?
The correct surgical site must be marked and include the patient in the marking process to eliminate wrong site surgery
Cording to the joint commission national patient safety goals what type of abbreviation for a medication might be confusing and therefore prohibited?
inclusion of the leading zero before the decimal
For example: 0.04 or 0.4
Which part of soap may include a differential diagnosis?
The assessment this includes both the subjective and the objective
What does the abbreviation SOAP stand for?
Subjective, objective, assessment, plan
What is the Master patient Index?
It cross-references the patient name and the medical record number
Where might a pharmacy consultation be seen?
long-term care facility
For whom is a pharmacy consult required?
Elderly patients are typically taking multiple medications
What in by whom is published in the Federal Register?
rules for conditions of participation for hospital published by seeing
What is the primary concern when developing a data collection system
The end-users need
When might an original paper-based patient health record physically be removed from the hospital?
When acting in response to a subpoena duces tecum taking the health record to court
Which piece of legislation mandates the use of minimum data set for long-term care?
OBRA 1987
How could you track down the name of a particular data field and security levels applicable to that field?
The facilities data dictionary
When does the COP require a consultation report?
For patients were not good surgical risks, patients with obscure diagnoses, patients for whom the physician has doubts as to the best therapeutic measure to be taken, and patients for whom there is a question of criminal activity.
What is an example of an objective type of data?
The physicians physical assessment of the patient
What does COP stand for?
Conditions of participation
According to COP and joint commission standards what is the time limit For completion of the H&P?
24 hours after admission or prior to surgery
True or false:the APA is an accrediting body for mental health?
False
Violation of HIPPA with intent to sell info for profit carries what potential fine and jail time?
Up to $250k and up to 10 years in jail
If the HIM director discovers MD’s are changing reports up to a week after transcription, what should she do?
Alert legal counsel
According to Medicare COP, All paper and electronic records must be authenticated and dated,
T or f!?
True
What is quantitative review?
analysis which involves checking for the presence or absence of necessary reports and or signature
What is the function of a deficiency analysis technician?
Conducting quantitative review such as checking for missing reports signatures are patient identification
Describe an integrated progress note:
When healthcare providers from every discipline document the progress notes sequentially on the same form
What does the acronym CARF stand for?
The commission on accreditation of rehabilitation facilities (accrediting agency for rehab facilities)
True or false: accreditation but the joint commission is voluntary
True it is voluntary however often is required for reimbursement or certain patient groups such as Medicare Medicaid
What are the four distinct components that make up a problem oriented medical record?
Database problem list initial plan and progress note
In the POMR name the component which makes up the history and physical
Database
In a POMR, name the component which includes titles numbers dates of problems, and serves as a table of contents for the record
The problem list
In a POMR what is included in the progress note?
Documentation of the progress of the patient throughout the episode of care summarized in a discharge summary or transfer
In a POMR what does the initial plan describe?
Diagnostic, therapeutic, and patient education plans
All Accession numbers are preceded by what?
The year
What is the RAC program?
Mandated to find and correct and proper Medicare payments also known as a rac audit
What databank must the credentials committee query prior to accepting a new physicians application? (Required by the healthcare quality improvement act of 1986)
National practitioner data Bank
What is a potentially compensable event?
In occurrence that could result in financial liability at sometime in the future
What is the patient certification period?
The 60 day time frame in which a summary is required for home health patients
What is the purpose of the medical staff rules and regulations?
Outline details for implementing principles including process and time frames for completing records and penalty for failure to comply
What is the first piece of clinical data collected at the time of inpatient admission?
Admitting diagnosis diagnosis
What is indicated by the absence of a discharge order?
Patient left against medical advice
If position wanted to search for a patient based on the date that they were admitted which register would be most beneficial?
The admitting register
True or false the protection of patient’s health information is addressed in the patriot act?
False
Does an incident report belong with the original medical record?
No it should be handled by QA but not contained within The patients record
Give several examples of an outcome measure
Patient mortality, infection and complication rate, adherence to living will requirements, adequate pain control and other documentation that describes the end result of care or measurable change in the patient’s health
Engaging patients and their families in healthcare decisions is one of the chore objectives for what?
Achieving meaningful use of EHR’s
In quality review activities, a department should focus on clinical processes that are what Three things?
high-volume, high-risk, problem prone
Describe the function of the interdisciplinary care plan
The foundation around which patient care is organized.
It contains input from each discipline involved, and assessment, statement of goals, identification of specific activities or strategies to achieve those goals and periodic assessment of goal attainment
What is an effective way to encourage physicians to improve documentation?
Regular in-service presentations on documentation including it’s importance tips for improvement
What is the goal of benchmarking?
To improve your departments processes
Define staging
A system for documenting the extent or spread of cancer
What healthcare organizations collect UHDDS?
All non-outpatient settings including acute care, short term care, long term care, and psychiatric hospitals, home health agencies, rehabilitation facilities, and nursing homes
Which of the following ethical principles is being followed when an HIT professional ensures thtat patient information is only released to those who have a legl right to access it?
Beneficence
The discharge summary must be completed within ________ after discharge for most patients but within __________ for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for less than __________ hours.
30 days / 24 hours / 48 hours
Which organization developed the first hospital standardization program?
American college of surgeons
What type of organization works under contract with the CMS to conduct Medicare and Medicaid certification surveys for hospitals?
State licensure organizations
What is the OIG’s work plan?
The document published by the OIG every year detailing their focus for Medicare fraud and abuse for that year
What coding system is utilized by inpatient psychiatric facilities prospective payment methodology for assignment and proper reimbursement
ICD-9 codes
Which coding system is utilized in the MS DRG prospective payment methodology?
ICD-9
Describe the hospital acquired conditions payment provision
CMS will not make additional payment for these conditions when they are not present on admission
Are nonparticipating Medicare providers still required to file all Medicare claims?
Yes
What is the name of the diagram which depicts grouper logic in assigning MS DRGs
Decision tree
How do you compute the reimbursement for a particular MS DRG?
Multiplying the hospital-based payment rate by the relative weight for the MS DRG
