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Cards In This Set
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In preparation for an 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 management system. The unnamed 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...
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Pathology report
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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 (Minimum Data Set), but NOT in the UHDDS would be...
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Cognitive patterns; The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems.
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In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the Commissions national patient safety goals, the focus has shifted to the...
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Use of prohibited or "dangerous" abbreviatioins
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Engaging patients and their families in health care decisions is one of the core objectives for...
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Achieving meaningful use of EHRs
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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...
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Incident report
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For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the...
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Problem list
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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...
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Evidence cannot be provided that the physician actually reviewed and approved each report
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As part of a quality improvement study, you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records. The best place in the record to locate this information is the...
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Prenatal record
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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 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...
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The H&P copy is acceptable as long as she documents any interval changes
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You have been asked to identify ever 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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Joint Commission requires the attending physician to countersign health record documentation that is entered by...
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Interns or medical students
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The minimal length of time for retaining original medical records is primarily governed by...
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State law
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The use of personal signature stamps for authentication of entries in a perper-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...
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Electronic signatures
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Discharge summary documentation must include...
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Significant findings during hospitalization
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The performance of qualitative analysis is an important tool in ensuring data quality. These reviewes evaluate...
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The overall quality of documentation
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