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Cards In This Set
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A coder who needed to locate the microscopic description of tissue excised during surgery would be most likely to find this information within the...
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...pathology report.
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You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility's...
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...disease index.
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A foundation for communicating all patient care goals in long-term care settings is the...
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...interdisciplinary patient care plan.
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For each report of care rendered to a patient, the health record entry should include the date plus the provider's name and ...
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...discipline.
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This is a resource that will be most helpful in providing standard definitions for data commonly colledted in acute care hospitals...
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...Uniform Hospital Discharge Data Set.
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An example of an objective entry in the health record supplied by a health care practitioner is the...
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...physical assessment.
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One of the essential item to be captured on the physical exam is the...
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... objective survey of body systems.
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Joint commission standards require that a complete history and physical be documented on the health records of operative patients. Does this report carry a time requirement?...
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...yes, prior to surgery.
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Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of ...
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...qualitative analysis.
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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...
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... documented in both the progress notes and the discharge summary.
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Accreditation by Joint Commission is a voluntary activity for a facility and it is ...
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...required for reimbursement of certain patient groups.
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This index might be protected from unauthorized access through the use of unique identifier codes assigned to members of the medical staff...
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...physician index.
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For inpatients, the first data item collected of a clinical nature is usually...
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...the admitting diagnosis.
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The ownership of the information contained in the physical medical/health record is considered to belong to the ...
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...patient.
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HIM professionals are bound to protect the confidentiality of patient information under the...
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...AHIMA's Code of Ethics.
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