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Related Flashcards
Cards In This Set
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In preparation for EHR, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document managment system. THe unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you most likely to give to this form is A. recovery room record
B. pathology report C. operative report D. discharge summary |
B. pathology report (C and D) although a gross description of tissue removed may be mentioned on the operative note or discharge summary, only the pathology report will contain a microscopic description.
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Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS, but NOT in the UHDDS would be A. personal identification
B. cognitive patterns C. procedures and dates D. principal diagnosis |
B. cognitive patterns Answers A, C, And D represent items collected on Medicare inpatients according to UHDDS requirements. Only B represents a data item collected more typically in long-term care settings and required in the MDS.
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In the past, Joint Commission standards have focused on promoting the use of facility-approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to the A. prohibited use of any abbreviations
B. flagrant use of specialty-specific abbreviations C. use of prohibited or "dangerous" abbreviations D. use of abbreviations in the final diagnosis |
C. use of prohibited or "dangerous" abbreviations The Joint Commission requires hospitals to prohibit abbreviations that have caused confusion or problems in their handwritten form, such as "U" for unit, which can be mistaken for "O" or the number "4". Spelling out the unit is preferred.
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In the number "10-0001" listed in a tumor registry accession register, what does the prefix "10" represent? A. the number of primary cancers reported for the patient
B. the year the case was entered into the database of the registry C. the sequence number of the case D. the stage of the tumor based upon the TNM system of staging |
B. the year the case was entered into the database of the registry Every case entered into the registry is assigned a unique accession number preceeded by the accession year, or the year the case is entered into the database.
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A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the A. doctor's progress notes
B. integrated progress notes C. incident reports D. nurses' notes |
C. incident reports Factual summaries investigating unexpected facility events should not be treated as part of the patient's health information and therefore would not be recorded in the health record.
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For continuity of care, abulatory care providers are more likely than providers of acute care services to rely on the documentation found in the A. interdisciplinary patient care plan
B. dishcarge summary C. transfer record D. problem list |
D. problem list (A, B, and C) Patient care plans, pharmacy consultations, and transfer summaries are likely to be found on the records of long-term care patients.
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Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that A. it is too easy to delegate use of computer passwordsB. evidence cannot be provided that the physician acutally reviewed and approved each report
C. electronic signatures are not acceptable in every state D. tampering too often occures with this method of authentication |
B. evidence cannot be provided that the physician actually reviewed and approved each report Auto authentication is a policy adopted by some facilities that allow physicians to state in advance that transcribed reports should automatically be considered approved and signed (authenticated) when the physician fails to make corrections within a preestablished time frame (e.g., "Consider it signed if I do not make changes within 7 days."). Another version of this practice is when physicians authorize the HIM department to send weekly lists of unsigned documents. The physician then signs the list in lieu of signing each individual report. Neither practice ensures that the physician has reviewed and approved each report individually.
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As part of a quality improvement study, you have been asked to provide information on the menstral history, number of pregnancies, and number of living children on each OB patient from a stack of old obstectrical records. The best place in the record to locate this information is the A. prenatal record
B. labor and delivery record C. postpartum record D. discharge summary |
A. prenatal record The antepartum record should include a comprehensive history and physical exam on each OB patient visit with particular attention to menstrual and reproductive history.
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As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical (H&P) 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 for every inpatient admission
B. that you apologize for not noticing the H&P provided C. the H&P copy is acceptable as long as she documents any interval changes D. Joint Commission standards do not allow copies of any kind in the original record |
C. the H&P copy is acceptable as long as she documents any interval changes Joint Commission and COP allow a legible copy of a recent H&P done in a doctor's office in lieu of an admission H&P as long as interval changes are documented in the record upon admission. In addition, when the patient is readmitted within 30 days for the same or a related problem, an interval history and physical exam may be completed if the orginial H&P is readily available.
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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 A. disease index
B. number control index C. physician's index D. patient index |
A. disease index The major sources of case findings for cancer registry programs are the pathology department, the disease index, and the logs of patients treated in radiology and other outpatient departments. B. The number index identifies new health record numbers and the patients to whom they were assigned. C. The physician's index identifies all patients treated by each doctor. D. The patient index links each patient treated in a facility with the health number under which the clinical information can be located.
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Joint Commission requires the attending physician to countersign health record documentation that is entered by A. interns or medical students
B. business associates C. consulting physicians D. physician partners |
A. interns and medical students Those who make entries in the medical record are given that privilege by the medical staff. Only house staff members who are under the supervision of active staff members require countersignatures once the privilege has been granted.
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The minimum length of time for retaining original medical records is primarily governed by A, Joint Commission
B. medical staff C. state law D. readmission rates |
C. state law The statute of limitations for each state is information that is crucial in determining record retention schedules.
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The use of personal signature stamps for authentication of entries in a paper-based record requires special measures to guard against delegated use of the stamp. In a completely computerized patient record system, similar measures might be utilized to govern the use of A. fingerprint signatures
B. voice recognition systems C. expert systems D. electronic signatures |
D. electronic signatures Authentication by signature stamps requires a written agreement with the facility not to delegate the use of the stamps. Similarly, in a computer-based system, it is important to ensure that personal identification codes used to authenticate entries are used only by the persons to whom they are assigned. A. Fingerprint signatures are individualized automatically.
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Discharge summary documentation must include
A. a detailed history of the patientB. a note from social services or discharge planningC. significant findings during hospitalizationD. correct codes for significant procedures |
C. significant findings during hospitalization
Some reference to the patient's history may be found in the discharge summary but not a detailed history. B. The attending physician records the discharge summary. D. Codes are usually recorded on a different form in the record. |
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The performance of qualitative analysis is an important tool in ensuring data quality. These reviews evaluate
A. quality of care through the use of pre-established criteriaB. adverse effects and contraindications of drugs utilized during hospitalizationC. potentially compensable eventsD. the overall quality of documentation |
D. the overall quality of documentation
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