R1

Question 1

Data governance

Answer 1

procedures and plans are available, and it encompasses security of structured and unstructured information

Question 2

Data Governance Includes

Answer 2

authority

decision making

Accountability

Question 3

OECD

Answer 3

Organization for economic cooperation and development

Goes over the relationship between Board of Directors managers and shareholders, etc.

Question 4

Data Governance Vs. Information Governance

Answer 4

• Data governance goes over the input of information.

- Information governments goes over how information is used and analyzed

Question 5

Data lifecycle management

Answer 5

Data planning, data inventory, and evaluation, capture, data transformation and processing, data access and distribution, data maintenance, data archival. And data distribution And data destruction.

Question 6

Data architecture management:

Answer 6

• Defined as specifications used to describe as existing state, defined data requirements, guide, data integration, and control data. Assets as put forth in a data strategy.
• Include establishing data standards, policies, and procedures for the collection, storage, and integration of enterprise data and design of information systems.
• Identifying and documenting data requirements that meet the needs and support the process of the organization.
• Developing and maintaining enterprise and conceptual data and process models that represent the organization’s business rules.

Question 7

Artifacts

Answer 7

.: developed through architecture, data management such as data models, use cases, data flow diagrams, and data dictionaries are as important to data management as the blueprints prepared by an architect are to a building design and maintenance.

Question 8

Metadata management

Answer 8

• structured information used to increase the effective use of data. Metadata is easier to locate, retrieve, use, and manage. Data Element name, data type, and field length are examples of Metadata That is used to describe data in databases.
• Plays an important role in achieving interoperability among different computer systems and providing search and navigation capabilities.

Question 9

Metadata management functions requiring data governance include the following:

Answer 9

managing data dictionaries.

Establishing enterprise metadata strategy.

Developing policies, goals and objectives to our metadata management and use.

Adopting metadata standards.

Establishing and implementing metadata metrics.

Monitoring procedures to ensure metadata policy implementation.

Question 10

Master data management:

Answer 10

• refers to master data that an enterprise maintains about key business entities, such as customers, employees, or patients, and to reference data that is used to classify other data or identify allowable values for data such as codes for state abbreviations or products.
• A good example of master data is the master patient index that includes master data on the key entity.: the patient., usually includes patient, medical record number, patient last, middle, and first names, birthday, gender, and address.

Question 11

Content management

Answer 11

encompasses managing growth structure data. For example, data stored in databases and unstructured data such as data contained in text documents.

Question 12

Data security management:

Answer 12

process in which organizations implement protection measures and tools for safeguarding data and information from unauthorized accidental or intentional modification, destruction, or use.

Question 13

Information, intelligence and big data:

Answer 13

business intelligence is defined as a broad category of applications and technologies for gathering, storing, analyzing, and providing access to data to help enterprises are users make Better Business decisions.

Question 14

Data quality management:

Answer 14

characterized as continuous process setting standards, building quality into the processes that create, transform, and store data, and measuring data against standards.

Question 15

Terminology and classification management:

Answer 15

consists of the processes for managing the breadth of healthcare terminologies, vocabularies, classification system, and data sets that an organization may use and also serves as terminology authority for the enterprise.

Question 16

American College of Surgeons and the Joint Commission:

Answer 16

ACS provided the impetus for standardizing health records when it developed minimum standards for hospitals early in the 20th century.

Question 17

The Joint Commission (TJC) is the

Answer 17

successor organization to the ACS in the area of standardization. In a joint effort of the ACS American College of Physicians, American Medical Association and American Hospital Association The Joint Commission was able to Accredit hospitals before they existed.

Question 18

The Joint Commission surveyors

Answer 18

routinely review the health records of current patients to obtain knowledge about the facilities, performance and process of care.

Question 19

Internal standards:

Answer 19

-bylaws, rules, and regulations are developed by the medical staff and approved by the board of trustees, or governing body in health care facilities.

Question 20

The bylaws outline

Answer 20

the content of patient health records, identify the exact personnel who can enter the information and health records, and may restate applicable Joint Commission and other requirements. They also describe the time limits for completing patient health records.

Question 21

Definition of the health record:

Answer 21

• the health record must outline and justify the patients treatment, support, diagnosis of the patient’s condition, described the patients progress in response to medication and services, and explain the outcomes of the care provided.
• Health record itself is the property of the health care facility.

Question 22

The longitudinal health care record

Answer 22

The Longitudinal health care record is a record compiled about an individual that contains health records from various encounters and from numerous healthcare delivery settings.

Question 23

Responsibility for quality documentation:

Answer 23

-ensuring data accuracy of health record content is one of the primary responsibilities of the HIM professional

Question 24

The provider of care is responsible for ensuring that entries made in the record

Answer 24

are of high quality. Please look at page 106 guideline. figure 4.1.

Question 25

Administrative Information:

Answer 25

• Administrative and demographic information is generally found on the front page or face sheet of the paper health record and on the login screen of the dashboard in an EHR.
• The data that it includes, it identifies the patient and data related to payment and reimbursement and other operational needs of the health care facility.

Question 26

Advanced directives:

Answer 26

• when a patient has a written advance directive, its existence must be noted in the health record
• The advance directive can be included as part of the health record, although its inclusion may not be a required.
• Patients must be informed that they have the right to have an advanced directive. Caring connections is the program of the National Hospice and palliative care organization and NHPCO.

Question 27

History

Answer 27

History is the summary of the patients illness from his or her point of view.

Question 28

Physical Examination

Answer 28

The physical examination is a comprehensive assessment of the patients physical condition through examination and inspection of the patients body by the practitioner. The end of the physical examination should include the impression, which is a list of the patients problems based on the information obtained.

Look at Table 4.1 on page 109:

Chief complaint

It’s really a present illness or present illness

Past medical history.

Social and personal history.

Family medical history.

Review of systems.

Question 29

The physical examination is conducted by

Answer 29

observing the patient, palpitating or touching the patient, tapping, the thoracic and abdominal cavities, listening to the breath and heart sounds, and taking the blood pressure.

Question 30

Time frame for the history and physical examination:

Answer 30

CMS conditioners of participation requires that the history and physical examinations also referred to as H&P be completed no more than 30 days before or 24 hours after admission and the report must be placed in the record within 24 hours after admission.

If a history and physical has been completed within the 30 days prior to admission there must be an updated entry in the medical record that documents an examination for any changes in the patient’s condition since the original history and physical examination and this entry must be included in the record within the first 24 hours of admission.

The history and physical examination must be completed by the physician or another qualified individual who has medical staff privileges in accordance with state line hospital policy.

Question 31

The joint commission requires a history and physical examination

Answer 31

to be recorded and made part of the patient health record prior to any operative procedure.

Question 32

Diagnostic and therapeutic orders:

Answer 32

Orders for Tests must demonstrate the medical necessity and explain the reason for the order

The legibility of orders is important to ensure that they are clearly understood by the personnel we must carry them out

Physcian or other credential practitioner or verbally communicated to persons qualified and authorized to receive and record verbal orders either in person or by telephone

Question 33

Verbal Orders

Answer 33

For verbal orders of person accepting the order should record the order read it back to the ordering physician sign it and give his or her title such as RN, PT, or LPN.

Verbal orders for medication are usually required to be given to you and to be excepted only by nursing or pharmacy personnel

The joint commission requires the documentation of verbal orders to include the date and names of individuals who gave, received, and implemented the orders.

Question 34

Signatures on orders:

Answer 34

Orders must be dated and authenticating manual or electronically by the treating practitioner responsible for the patients care who gave the orders.

Many facilities require the ordering practitioner to indicate that the telephone orders are accurate complete and final by authenticating them in writing or electronically within 24 hours.

CMS regulations allow verbal orders to be signed by another provider responsible for the patient’s care even if the order did not originate with that provider.

Question 35

Other types of orders: drugs, DNR, and restraint orders

Answer 35

Narcotics and sedatives have a automatic time limit or stop order.

Do not resuscitate orders must contain documentation that the decision to withhold resuscitative services was discuss when the decision was made and who participated in the decision this discussion is often documented in the progress notes.

Specific time limits for seclusion and restrain orders must be followed and there must be continuous oversight of the patient

Question 36

Discharge orders:

Answer 36

Discharge orders for hospital patients must be documented in the health record and can only be issue via physician.

When a patient leaves against medical advice this fact should be noted in lieu of a discharge order because the patient was not actually discharged.

Question 37

Progress notes:

Answer 37

chronological statements about the patient’s response to treatment during his or her stay in the facility.

Question 38

Integrated progress note

Answer 38

some facilities have various practitioners record progress notes on a common form or within one electronic section
while another record formats there may be separate section for physician, nursing, and therapy progress notes

Question 39

Consultation

Answer 39

Opinions of physicians with specialty training beyond general board certification.

Question 40

Nursing services:

Answer 40

Nurses begin recording information in the health record when the patient is admitted to the facility

Summarize the date, time, and method of admission; the patient’s condition, symptoms, and vital signs; and other information

All nursing knows must be signed by the individual who provided the service or observed a patient condition full names and titles are required with each entry

Question 41

Charting by exception

Answer 41

or focus charting is a method of documenting only unusual findings where deviations from the prescribed plan of care occurred

Question 42

Medication administration records are maintained

Answer 42

by nursing staff or all patients and include medications given, time, form of administration, and dosage and strength.

Question 43

Ancillary services:

Answer 43

Laboratory and radiology reports and reports from other services such as electrocardiograph and electroencephalograph must be signed by the physician responsible for the interpretations

Question 44

The operative report must be documented

Answer 44

either in writing or dictated by the surgeon immediately after surgery I must include the names of the surgeon and assistance, the names of the procedures performed, a description of the procedures, findings of the procedures, any specimens removed, any estimated blood loss, and the postoperative diagnosis.

Question 45

The operative section of the health record

Answer 45

includes the anesthesia record, the interoperative record, and the recovery record

Question 46

Every patient’s record must include a complete history and physical examination prior to any surgery or invasive procedure unless there is an emergency.

Answer 46

any surgery or invasive procedure unless there is an emergency

Question 47

The joint commission standards require that prior to high-risk procedures and those involving use of anesthesia or deep sedation

Answer 47

a provisional diagnosis is recorded by the licensed independent practitioner involved in the patient’s care.

Question 48

There must be a preanesthesia evaluation or an updated evaluation prior to surgery and it must cover information on the anesthesia use, risk factors, allergy and drug history, potential problems, and a general assessment of the patient’s condition. In interoperative anesthesia record must be maintained of all events during surgery including complete information on the anesthesia administration, blood pressure, pause, respiration, and other monitors of the patient’s condition. Finally after surgery the appropriate anesthesia personnel must document I post operative anesthesia follow up report including any anesthetic complications.

Answer 48

information on the anesthesia use, risk factors, allergy and drug history, potential problems, and a general assessment of the patient’s condition

Question 49

• In intraoperative anesthesia…

- Finally after surgery the appropriate anesthesia personnel must document

Answer 49

• the record must be maintained of all events during surgery including complete information on the anesthesia administration, blood pressure, pause, respiration, and other monitors of the patient’s condition.
• Finally after surgery the appropriate anesthesia personnel must document post-operative anesthesia, follow-up report including any anesthetic complications.

Question 50

The joint commission requires the health record contain post-operative information,

Answer 50

including the patient’s vital signs, level of consciousness, medications including fluids, and any dispense blood or blood products; and any unforeseen incidents or complications and the handling of those occurrences

Question 51

The surgeon must enter a brief operative progress note in the record

Answer 51

immediately after surgery before the patient is transferred to the next level of care.

Question 52

The autopsy report includes exam details provided by the medical exam or pathologist that leads to a determination of a

Answer 52

cause of death. it will contain a summary of a disease process or trauma along with related treatments, gross and microscopic findings, and at clinical diagnosis.

A provisional diagnosis should be documented in the chart within three days and the final report should be made part of the chart within 60 days of the examination

Question 53

Autoposy Reporting

Answer 53

A provisional diagnosis should be documented in the chart within three days and the final report should be made part of the chart within 60 days of the examination

Question 54

Organ transplantation

Answer 54

CMS and joint commission require hospitals to inform families of the opportunity to donate organs, tissues, or eyes. All the patients meeting the united network of organ sharing UNOS criteria must be evaluated in the documentation must be part of the health record. Documentation showing that the organ procurement organizations OPO must be notified regarding a deceased patient or a patient your dad must be included in the health record so the anatomical gift can be preserved and use.

Question 55

For obstetrical cases, the health record includes

Answer 55

the antepartum record, the labor and delivery record, and the postpartum record. The ante-partum of the prenatal record is information usually collected in the physicians office before the birth event and made it available to the hospital by the 36 week of pregnancy.

Question 56

The labor and delivery record is information collected

Answer 56

the time the patient is admitted to the hospital through to the delivery.

Question 57

The postpartum record provides details about the patient

Answer 57

after delivery through the recovery process.

Question 58

Discharge Summary

Answer 58

• Also called the clinical resume it provides details about the patient stay well in the facility and the foundation for future treatment.
• It is prepared when the patient is discharged or transferred to another facility or when the patient dies. The summary states that patient’s reason for hospitalization and gives a brief history explaining why he or she needed to be hospitalized.

Question 59

In addition to describing the patient’s conditions at discharge, the discharge summary gives

Answer 59

specific instructions given to the patient or family for future care, including for information on medication, referrals to other providers, diet, activities, follow-up visit to the physician, and the patient’s final diagnoses.

Question 60

if a patient dies in the hospital the facility often requires the physcian

Answer 60

who pronounced the death to write a note that gives the time of death. No matter how long they were in the facility this documentation is required.

Question 61

A discharge summary is not typically required for patients who are in the hospital for 48 hours or less.

Answer 61

who are in the hospital for 48 hours or less.

Question 62

When the patient dies 48 hours or less after admission, the short stay record is

Answer 62

insufficient and a complete discharge summary must be prepared.

Question 63

the discharge summary must be completed within

Answer 63

30 days after discharge; however facility policy may require a quicker completion date.

Question 64

When a patient has transferred the physician should complete the discharge summary within

Answer 64

24 hours.
-the joint commission allows where a transfer summary and the patient is transferred to another level of care in the facility or the patient here is transferred to another provider.

Question 65

Emergency care may be filed

Answer 65

separately or incorporate into the health record when the patient is admitted to the same facility.

Question 66

When the patient leaves the emergency department before being seen against medical advice this fact should be noted

Answer 66

on emergency department form.

Question 67

Emergency department records must maintain

Answer 67

• a chronological record or log of all patients visiting the emergency department with the name, date, time, of arrival, and record number.
• This register also includes the names of patients who were dead on arrival.

Question 68

Emergency medical treatment and labor act EMTALA:

Answer 68

states that patient cannot be transferred or refuse treatment for reasons related to ability to pay or source of payment nor can hospitals determine that space is unavailable based on ability to pay or source of payment.

Question 69

The accreditation Association for ambulatory healthcare AAAHC Has additional requirements for the content of the

Answer 69

ambulatory care record that are provided for ambulatory surgery centers ASC, community health centers, health plans and medical homes, office base surgery centers, and primary care.

Question 70

Ambulatory facilities that only perform surgery are called

Answer 70

Ambulatory facilities that only perform surgery are called ASCs -ambulatory surgery centers.

Question 71

The Medicare conditions of participation requires that the inpatient within a psychiatric hospital

Answer 71

• receive a psychiatric evaluation.
• A discharge summary discussing whether or not a treatment goals have been met or further treatment is necessary along with plans for aftercare should also be noted

Question 72

NAHC

Answer 72

national Association for home care and hospice

Question 73

Home health services documentation requires

Answer 73

• Patient health records must contain a legible record of each visit describing what was done to offer the patient during the visit. Developed and documented periodic plans of care
• Attending position to document an update the plan of care. It is also necessary for the physician to certified the patients need for care, and recertification of the need must be documented periodically.

Question 74

Hospice care services: NHPCO

Answer 74

Hospice care is he oriented approach to expert medical care, pain management, and emotional and spiritual support expressively tailored to the patient’s needs and wishes.

Must have certificate cation by the patients attending position in the hospice that the patient has its terminal illness.

Question 75

rehabilitation setting requirements

Answer 75

• the history and physical must include a functional history covering the patient’s functional status before an after injury or onset of illness.
• Additionally the history she described equipment the patient is at home, including orthotics and prosthetics. Is important that the physician outlined the goals for the patient care to coordinate the interdisciplinary team involved in the case

Question 76

Rehabilitation services are

Answer 76

• often part of the long-term care plan
• The long-term care record must document a comprehensive assessment that includes items in a minimum data set to meet CMS requirements.

Question 77

Individualized patient care plans must be developed and included

Answer 77

in the record and they must cover the potential for rehabilitation, your ability to perform activities of daily living, medication prescribed, and other aspects of care.

Question 78

Source oriented health records:

Answer 78

Is the conventional or traditional method of maintaining paper base health records. Health records are organized according to the source, or originating, department that rendered the service. Example hybrid health record systems.

Question 79

Distinctive feature is the problem list which serves as a record table of contents. All relevant problems that may have an impact on the patient are listed with a number. As the problems are resolved the resolution is noted on the list and new problems are added as they occur. The problem with serves as a permanent index that providers can quickly check to review the status of past and current problems.

Most recognizable component of the POMR is the SOA P format which is a method for recording progress notes. It is an easy acronym that helps providers remember the specific and systematic decision making process after reading documentation.

soap: subjective findings, objective findings, assessment, plan look to page 1 to 1

Question 80

the POMR is compromised of the

Answer 80

problem list, the database which includes the history and physical examination and initial lab findings, The initial plan, and any progress notes organized so that every member of the healthcare team can easily follow the course of the patient treatment.

Question 81

POMR (Problem oriented health record)

A Distinctive feature is the problem list is that it

Answer 81

• serves as the records table of contents.
• All relevant problems that may have an impact on the patient are listed with a number. As the problems are resolved the resolution is noted on the list and new problems are added as they occur. The problem with serves as a permanent index that providers can quickly check to review the status of past and current problems.

Question 82

SOA P format which is a method for

Answer 82

• recording progress notes. It is an easy acronym that helps providers remember the specific and systematic decision-making process after reading documentation.
• soap: subjective findings, objective findings, assessment, plan look to page 101

Question 83

Integrated health records

Answer 83

arranged in strict chronological order

The order of the record is determined by the date the information was entered, the date of service, or the date the report was received, rather than by the source department; the record gives the sequence of the patient’s care as delivered.

Although the system makes it difficult to find a particular document unless you know the date it does provide a better picture of the story of the patient care, physician offices often use this format

Question 84

Abstracting:

Answer 84

process of reviewing the patient record and collecting pertinent data elements, usually in an electronic database.

Question 85

The purpose of abstracting is to make information from the patient record

Answer 85

• readily available for internal and external reporting aids. At tracking support the secondary use of patient that of her registries, public reporting, research, another purposes.
• It is important for the HIM professional to understand the mission of the facility when determining both the amount of data to abstract from the health record inappropriate staff required for the abstracting.

Question 86

Quantitative analysis: it is called a discharge analysis and it is a review of the health record for the completeness and accuracy.

Answer 86

it is called a discharge analysis and it is a review of the health record for the completeness and accuracy.

Question 87

current analysis:

Answer 87

the record is analyzed during the patient’s day and the healthcare facility it has the advantage of HIM or other personnel being present in the clinical care units where the physician sees patients.

Question 88

The record is often organized in

Answer 88

reverse chronological order with the most recent information in the front of each record section.

Question 89

Amendments to the record

Answer 89

Any corrections or amendments to the records must be entered properly. For electronic entries, a procedure should be followed that explains how to correct errors and enter an addendum to the house record including the current date and reason for the information being added to the record.

Question 90

Qualitative analysis:

Answer 90

review the quality and adequacy of record documentation and ensure that is in accordance with the policies, rules, and regulations established by the facility; the standards of licensing in accrediting bodies; and government requirements.

Question 91

More in-depth review of health records although the processes may overlap it is done while the patient is in the facility or under active treatment is called open record revealed.

Joint commission requires an open record review to ensure that its documentation standards are met at the point of care delivery.

Open review process looked at requirements such as presence of the history and physical examination prior to surgery and whether it thoroughly describes the condition of the patient upon admission, completion of the post operative note with our requirements document, and many other aspects of care process as documented in the health record. Open record review should be done on a continuous basis.

Close record review it means that the qualitative review is done retrospectively following discharge or termination of treatment. The problems in the care process that are revealed through the review can be corrected immediately. It is important because it is a way to obtain information about trends and patterns of documentation.

Question 92

Joint commission requires an open record review

Answer 92

to ensure that its documentation standards are met at the point of care delivery.

Question 93

Open review process:

Answer 93

looked at requirements such as presence of the history and physical examination prior to surgery and whether it thoroughly describes the condition of the patient upon admission, completion of the post operative note with our requirements document, and many other aspects of care process as documented in the health record. Open record review should be done on a continuous basis.

Question 94

Close record review it means

Answer 94

that the qualitative review is done retrospectively following discharge or termination of treatment. The problems in the care process that are revealed through the review can be corrected immediately. It is important because it is a way to obtain information about trends and patterns of documentation.

Question 95

Criteria for adequacy of documentation:

Answer 95

Documentation must reflect the care rendered to the patient and patient’s response to care. It must be timely and legible and authenticated by the person who wrote it.

Timeliness and legibility are two of the main areas of focus for accreditation and licensure bodies.

Question 96

Authentication for health record entries:

Answer 96

The joint commission allows rubberstamp fast mail signatures when there is a statement verifying that the position is the one who will use the stand and will maintain control of it. However many facilities no longer allowed to use of rubberstamp signatures or limited used to specific circumstances.

The signature is an electronic signature in to be used to sign a document

Question 97

Although the facility’s governing body has overall responsibility for patient care, responsibility for the delivery and documentation of patient care is delegated to

Answer 97

the medical staff

Question 98

The providers are responsible for the documentation in

Answer 98

the medical record, authenticating it, and completing it

Question 99

Storage, retrieval, and tracking of incomplete records:

Answer 99

Convenient for the providers as deficient health records maybe simultaneously ratted multiple for riders for a work love software. It is more efficient than the paper base routing of health records as it requires fever HIM personality locate, transport, and re-file the paper base house record. It is also more efficient for the provider she may access, authenticate, and complete the hybrid record or fully electronic health health remotely.

Question 100

Records are considered deficient or incomplete immediately at

Answer 100

discharge

Question 101

Delinquent health records are those records that are not

Answer 101

completed within a specific time frame for example within 14 days of discharge.

Question 102

Most facilities require that records be completed within

Answer 102

30 days of discharge as mandated by CMS regulations and joint commission standards.

Question 103

Unit numbering system

Answer 103

Most large facilities use a unit number in system and the patient is assigned a number during the first encounter for care and keep it for all subsequent encounter.

Question 104

Serial unit numbering system

Answer 104

patient is issued a different number for each admission or encounter for care and the records of past episodes of care are brought forward to be filed under the last number issued.

Question 105

Straight numeric filing system:

Answer 105

records are filed in numerical order according to the number assigned. The shortcoming of this is that most of the file activity is where the most recent numbers I’ve been assigned.

Question 106

Terminal digit filing system:

Answer 106

records are filed according to a three part number made up of two digit pairs. It is red from right to left. Terminal DJ piling concepts maybe I’ll see you like to evenly distribute lose paperwork filing and the doctors in complete area.

Question 107

Master patient index is a

Answer 107

permanent database including patient identify a little data for every patient ever admitted to or treated by the facility. Even though patient has records maybe destroyed after legal attention. Have been met, the information that came in the NPI must be kept permanently.

Question 108

Overlap

Answer 108

occurs when a patient has more than one medical record number assigned across more than one database.

Question 109

Overlay occurs

Answer 109

when one patient record is overwritten with dad from another patient record.

Question 110

Open shelf filing is the least expensive option for storage of paper records. Shelves are usually arranged back to back like shelving in a library. Shelving uses space more efficiently than file cabinets because only 30 to 36 inches are needed for each aisle.

Answer 110

least expensive option for storage of paper records. Shelves are usually arranged back to back like shelving in a library. Shelving uses space more efficiently than file cabinets because only 30 to 36 inches are needed for each aisle.

Question 111

Lateral files with drawers and doors also require

Answer 111

sufficient aisle space for opening the individual drawers in allowing personnel to pass.

Question 112

Record retention involves

Answer 112

determining the schedule to be followed to protect and preserve active and inactive records.

Question 113

Disposition involves the process of

Answer 113

destroying the records once the end of the retention period has been reached

Question 114

The HIM professional must adhere to the strictest time limit of the

Answer 114

recommended retention

Question 115

CMS requires health records to be

Answer 115

maintained for at least five years.

Question 116

OSHA requires records of employees with occupational exposure to be maintained

Answer 116

for the duration of employment +30 years.

Question 117

Radiology: the sign interpretation of the studies must be maintained in the record for

Answer 117

the full retention. Required by law.

Question 118

Mammograms must be maintained maintain for

Answer 118

5 to 10 years depending on whether or not additional mammograms are performed.

Question 119

Many states recommend that patient has records be retained

Answer 119

for 10 years following patient discharge or death. There are special requirements for minors. There are also special required meds for newborns.

Question 120

Keep records to the

Answer 120

maximum or strictest time required

Question 121

When the required retention schedule has been satisfied

Answer 121

a complete list of records to be destroyed should become filed and submitted to the individual designated to authorize the destruction

Question 122

Quality is the degree to

Answer 122

which health services for individuals in populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

Question 123

Performance is the

Answer 123

execution of a task

Question 124

Performance improvement refers to

Answer 124

the continuous study in adaptation of a healthcare organization functions and processes to increase the likelihood of achieving desired outcomes.

Question 125

Medical male practice liability refers to

Answer 125

insisting civil claims for damages against the healthcare provider successfully proves that the provider was negligent and their care of the patient leading to injury or death.

Question 126

Title XIX of the social security amendments 1965 Created the

Answer 126

Medicare and Medicaid programs-providing health insurance coverage to Americans age 65 and older as well as those with disabilities and certain medical conditions, and the latter providing insurance coverage to low income individuals and families

Question 127

Conditions for coverage CFC and conditions of participations COP

Answer 127

needed in order to begin and continue participating in the Medicare and Medicaid programs. They are Health and safety standards for each applicable provider setting.

Question 128

adverse event refers

Answer 128

to instances in which medical care causes injury.

Question 129

Health maintenance organization act of 1973:

Answer 129

allowed for federal funding in the exploratory implementation of health maintenance organization. The government believe that HMO is a health insurance model that uses approaches such as referrals only occurring at the request of her primary care physician and predetermined based rate of pre-payment to providers have the ability to influence healthcare delivery by lowering costs and increasing quality.

Question 130

Institute for health care improvement IOH focuses on

Answer 130

applying scientific methods and quality management to improve healthcare is most challenging issues such as the capability for improvement in healthcare delivery; personal and family centered care; patient safety; and achieving quality, cost, and value.

Question 131

Triple Aim

Answer 131

identifies that vast and systematic improvements are needed in order to improve experiences for patients in their pursuit of healthcare, enhance health among the population, and lower per capita cost.

Question 132

Accreditation

Answer 132

voluntary process of organization review in which an independent body created for this purpose periodically evaluates the quality of the entities work against preestablish written criteria.

Question 133

Accreditation Helps healthcare organizations

Answer 133

because it portrays them as committed to meeting high standards, and accreditation status can be used in marketing strategies to attract patients and as a pathway for healthcare organizations to maintain their participation in the Medicare and Medicaid programs. The federal grabber is the largest single payer for health services.

Question 134

Emergency medical treatment and active labor act EMTALA

Answer 134

enacted to ensure public access to emergency service regardless of ability to pay.

Question 135

Clinical laboratory improvement amendments CLIA enacted to ensure quality labor testing.

Answer 135

to ensure quality labor testing.

Question 136

Medicare prescription drug, improvement, and modernization act was enacted to amend

Answer 136

title XVIII The Social Security act provide for a voluntary program for prescription drug coverage under the Medicare program to modernize the Medicare program to amend the internal revenue code of 1986 to allow deduction two individuals for amounts contributed to health savings security accounts and health savings accounts to provide for the disposition of unused health benefits in cafeteria plans and flexible spending arrangements and for other purposes.

Question 137

Health information technology for economic and clinical health HITECH:

Answer 137

enacted as part of the American recovery and reinvestment act of 2009 to promote the adoption and meaningful use of information technology, address privacy and security concerns associated with the electronic transmission of health information.

Question 138

Quality indicators are standards

Answer 138

against which actual care may be measured to identify a level of performance for that standard

Question 139

Value based payments can be thought of as

Answer 139

any method of healthcare reimbursement that either financially incentivizes providers we’re good quality outcomes are penalizes providers for an adequate quality an unfavorable outcomes.

Question 140

Benchmarking is the

Answer 140

systematic comparison of the products, services, and outcomes of one organization with those of a similar organization, or the systematic comparison of one organizations outcomes with regional or national standards.

Question 141

internal benchmarking is used to

Answer 141

identify best practices within an organization to compare best practices within an organization and to compare current practice overtime.

Question 142

External benchmarking occurs when

Answer 142

an organization uses comparative data between organizations to judge performance and identify improvements that have proven to be successful in other organizations.

Question 143

Explicit knowledge includes

Answer 143

documents databases and other types of recorded and documented information and tasset knowledge is the actions experience ideals values and emotions of an individual that temp to be highly personal and difficult to communicate.

Question 144

The healthcare quality improvement act of 1986 is a federal law that establishes

Answer 144

standards and requirements related to peer review among physicians in the legislation peer review is also referred to as professional review. When an incident has occurred and it is believed that peer review should occur healthcare organizations must follow standards to ensure that any actions taken against the physician are appropriate and justified.

This includes that the review is occurring to advance quality that reasonable efforts to obtain a relevant facts pertaining to the Internet have been made that the position under review is given advance notice and is afforded as fair hearing and there any actions taken are justified based on facts.

Question 145

The healthcare quality improvement Act of 1986 also provides

Answer 145

legal immunity to other positions who participate in P-Review activities this helps ensure that competent physicians will willingly participate in review of their peers without the threat of legal implications when the review occurs in accordance with the law.

Question 146

The national practitioner data bank is an information clearinghouse…

Answer 146

To collect and release certain information related to the professional competence and conduct of positions, dentist, and, in some cases, other healthcare practitioners. It is a database to provide medical malpractice payments; adverse licensure actions including revocation, suspensions, reprimand, censures,, probation, and surrenders of licenses for quality of care purposes only; in certain professional review actions taken by healthcare entities such as hospitals against physicians, dentist, and other healthcare providers.

Question 147

Entities making malpractice payments, including insurance companies, boards of medical examiners, and entities such as hospitals and professional societies, must report to

Answer 147

the NPDB.

include information on the practitioner, they’re reporting into, and the judgment or settlement went applicable.

Question 148

Credentialing

Answer 148

screening process to evaluate and validate a physicians qualifications for staff membership.

Question 149

Tracer methodology:

Answer 149

it is a process that the joint commission surveyors used during the on-site survey to analyze an organization systems with particular attention to identify priority focus areas, by following individual patients through the organization childcare process in the sequence experience by patient; an evaluation that follows or traces the hospital experiences of specific patients to assess the quality of patient care; part of the new joint commission survey process.

Question 150

Tracer Methodology allows for

Answer 150

Allow for peers within organizations to assess care processes, evaluate the environment of care, and contact benchmarking with accreditation standards is why healthcare organizations use tracer methodology.

Question 151

Outcomes and effectiveness research OER:

Answer 151

describes interprets and predicts the impact of healthcare interventions on any points that matter to patients families and caregivers providers private and public payers and purchasers healthcare regulatory agencies healthcare accrediting organizations and society generally

Question 152

Comparative effectiveness research:

Answer 152

the purpose of it is the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnosed, treat, and monitor a clinical condition for true improved the delivery of care. It is to help consumers, clinicians, purchasers, and policy makers to make informed decisions that will improve healthcare about the individual and population levels.

Question 153

Patient centered outcomes research Institute PCORI is an

Answer 153

entity funded through the patient center research trust fund which was established by the ACA at 2010. It helps in form and make sure that information is available for healthcare decision making.

Question 154

AHRQ

Answer 154

to support health services research design to improve the outcomes and quality of healthcare, reduce costs, address patient safety and medical errors, and broaden access to effective services. The research that they provide it helps people make better decisions about healthcare.

HCUP

Question 155

evidence-based practice is

Answer 155

the integration of clinical expertise, patient values, and the best research evidence into the decision making process for patient care.

Question 156

Clinical pathways are sometimes referred to as

Answer 156

critical pathways and they are structured multidisciplinary care plans that details essential steps in the care of patients with a specific clinical problem.

Question 157

The use of clinical pathways in patients has been shown to

Answer 157

reduce readmissions, improve outcomes, as well as support consistency and clinical care. They expand the concept of a care plan because the pathway is established with the intent that the care plan accounts for the needs of the patient as well as promotes the interdependent nature of the health professions to achieve more cohesive patient care.

Question 158

Case management:

Answer 158

The collaborative process of assessments, planning, facilitation, care coordination, evaluation, and advocacy for options and services to me and individuals and families comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.

offers a solution to help ensure that the needs of patients are met during a hospitalization or other care episode as well as after they are discharged from the healthcare setting.

Chronic conditions and helps reduce readmissions.

Question 159

Care coordination:

Answer 159

It is the act of organizing patient care activities and sharing information among all of the participants concern with the patient’s care to achieve safer and more effective care.

It is necessary to ensure that a patient is provided care at the appropriate level as well as to ensure that the care is coordinated and thoughtful and proactive ways and reflects an opportunity to provide healthcare services in a way that is proactive versus reactive in nature.

Question 160

DaTa stewardship and information governance are

Answer 160

strategic concepts in the management of health information.

Question 161

Help data stewardship pertains to

Answer 161

the responsibilities that best insure appropriate use of help data.

Effective data stewardship and information governments are necessary to maximize the value of health information available in health records used to evaluate and measure quality of care.

Question 162

Data analytics:

Answer 162

Effective at data analytics only occurs when those performing the analysis fully comprehend the complexity, limitations, meaning, and uses of healthcare data