In the number 10-0001 listed in a tumor registry accession register, what does the prefix "10" represent
C. They year the case was entered into the database registry
You have been asked to identify every reportable case of cancer reported in your facility form the previous year. A key resource will be the:
D. Disease index
For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the:
B. Problem List
When developing a data collection system, the most effect approach first considers
A. the needs of the end user
Which of the following is a secondary data source that would be used to quickly gather the health records of all juvenile patients treated for diabetes
C. Disease index
In determining the degree of compliance with prospective payment requirements for medicare at an acute care facility , the best resource to reference for recent certification.
C Federal register
In preparation for an upcoming site visit by the Joint Commission , you discover that the number of delinquent records for the preceding month exceeded 50% of discharged patients. Even more alarming was the pattern you noticed in the type of delinquencies. Fifteen person of delinquent records show
A. Missing operative reports
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 govern the use of
D. Electronic signatures
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 National Patient Safety Goals, the focus has shifted to the
B. Use of prohibited or dangerous abbreviations
Setting up a dropdown menu to make sure that the registration clerk collects "gender" as either "male, female or unknow" is an example of
C. Precision
In preparation for an EHR, you are conduction 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 doucments in front of you includes a microscopic description of tissue excised is
B. Pathology report
Gerda Smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. According to her sister. Gerda has had a recent medical history taken at the public health department. The physician on call is greatful that she can access this patient information using
C. the area RHIO
Medicare rules state that the use of verbal orders cannot be written or gievn electronically. In addition, verbal orders must be:
B. Recorded by the person autthorization by hospital regulation and procedures
For Continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the
D. Problems LIst
The performance of qualitative analysis is an important tool in ensuring data quality. These reviews evaluate
B. the overall quality of document
Ultimately responsibility for the quality and completion of entries in patient health records belongs to the
A. Attending Physician
As the director of a Health Information Technology Program, your community college has been selected to participate in the workforce development of electronic health record specialist as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need to regularly access the website of this governmental agency.
B. ONC
As Part of the Joint Commissions National Safety Goal Initiative, acute care hospitals are now required to use preoperative verification process to confirm the patient's true identity and to confirm the necessary documentation such as x-ray or medical records are available. They also develop and use a process for
A. marking the surgical site
The First Patient with cancer seen in your facility on Jan 1, 2012, was diagnosed with colon cancer with no known history of previous malignancies. The accession number assigned to this patient
B. 12-0001/00
Johns 487
Setting up a drop down menu to make sure that the registration clerk collects "gender" as male, female or unknown" is an example of ensuring data
B. Precision
In determining you acute care facility's degree of compliance with prospective payment requirements for medicare, the best resource to reference for recent certification standards is the for Medicare, the best resource to reference for recent certifications standards is the
D. Federal Register
In an acute care hospital, a complete history and physical may not be required for a new admission when
C. a legible copy of the recent H&P in the attending physician's office is available
The authors of all entries in a healthcare record should be:
A. identified by bio-metrics
which is the most serious type of delinquent record problems
B. Delinquent due to missing H&P
Using the SOAP style of documenting progress notes, choose the subjective statement from the following:
D. patient states low back pain is as severe as it was on admission
In 1987. OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each SNF resident defined in the
