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In the past, the Joint Commission standards focused on promoting the use of a 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 ✔✔use of prohibited or "dangerous" abbreviations 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 ✔✔incident report For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the ✔✔problem list The federally mandated resident assessment instrument used in long term care facilities consists of three basic components, including the new care area assessments, utilization guidelines, and the ✔✔MDS or minimum data set As Director of HIT program, your community college has been selected to participate in the workforce develeopment of electronic health specialits as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need regular access to the Web site of this governmental agency. ✔✔ONC
A qualitative review of a health record reveals that the h and p for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the h and p are true in the situation? Completion and charting of h and p indicates ✔✔noncompliance with JC standards. H and P must be completed within 24 hours The first patient with cancer seen in your facility on January 1, 2012, was diagnosed with colon cancer with no known history of previous malignancies. The accession number assigned to this patient is ✔✔ 12 - 0001/00 because in accession number 12 represents the year the patient first entered the database, 0001 represents the first case entered that year, and 00 indicates no previous known neoplasm. Setting a drop down menu to make sure the registration clerk collects gender as male or female is a method of ensuring data ✔✔Precision Validity refers to the accuracy of data, while reliability refers to the consistency of the data. Timeliness refers to the data being available when needed, and precision refers to data values that are just large enough to support the application process. In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is ✔✔The Federal Register CMS publishes both proposed and final rules for the Conditions of Participation for hospitals in the daily Federal Register.
An example of objective entry in the health record supplied by a health care practitioner is the ✔✔Physical Assessment. The medical history, including a review of systems and chief complaint, is information supplied by the patient. As Chair of the Health Record Committee you have been asked to reccommend a time limited documentation standard for inclusion in medical staff bylaws, rules, and regulations. that must meet standards of both JC and Medicare COP. For H&P you advise the time period for completion should be set at ✔✔24 hours after admission or prior to surgery An example of a primary data source for health care statistics is the ✔✔hospital census Which of the following is LEAST likely to be identified by a definciency analysis technician ✔✔Discrepancy between post-op diagnosis by the surgeon and pathology diagnosis by the pathologist In your facility it has become critical that information regarding patients who are transferred to the oncology unit be sent to an outpatinet scheduling system to facilitate outpatient appointments. This information can be obtained most efficiently from ✔✔R-ADT system also known as the registration-admission, discharge and transfer system Which method of authorship or authentication of entries would be inappropriate to use in a patient's health record? ✔✔Delegated use of a computer hey by radiology secretary.
Use of codes and stamped signatures MUST be confined to the owners and they are never to be used by anyone else. Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of ✔✔Qualitative review Which of the four distinct components of the problem oriented record serves to help index documentation throughout the record ✔✔Problem list Select the appropriate situation for which a final progress note may legitimately be substituted for a discharge summary in an inpatient medical record ✔✔Baby Boy Hiltz, born 1/5/2011, maintained normal status, discharged 1/7/ Stage I of meaningful use focuses on data capture and sharing. Which of the following is included in the menu set of objectives for eligible hospitals in this stage? ✔✔Use CPOE for medication orders Using a template to collect data for key reports may help to prompt caregivers to document all required elements in the patient record. This practice contributes to data ✔✔Comprehensiveness A primary focus of screen format design in a health record computer application should be to ensure that ✔✔The user is capturing essential data elements
According to terminal digit filing, what would be the number of the record immediately after record 99- 99 - 30 ✔✔ 00 - 00 - 31 The function of a is limited to data retrieval ✔✔Clinical data repository A coder notes that a patient is taking prescrition Pilocarpine. The final Dx is CHF and DM. The coder should query about adding DX of ✔✔Glaucoma Which of the following classification systems was designed with the electronic systems in mind and is currently being used for problem lists, ICU monitoring, patient care assessments, data collections, medical research studies, clinical trials, disease surviellance, and image d? ✔✔SNOMED CT The method of calculating errors in a coding audit that allows for benchmarking with other hospitals, and permits the reviewer to track errors by case type is the ✔✔record-over-record method The most common type of registry located in hospitals of all sizes and in every region of the country is the ✔✔cancer registry The cancer committee at Wharton General Hospital wants to compare long-term survival rates for pancreatic cancer by evaluating medical versus surgical treatment. The best source is the ✔✔Cancer registry abstracts
All of the following items are packaged under the Medicare OPPS except ✔✔Medical Visits How many major Dx categories are there in the MS-DRG system? ✔✔ 25 The standard form used by hospitals to request reimbursement for inpatient and outpatient procedures performed or services provided is called the ✔✔UB- 04 Currently which PPS is used to determine the payment to the physician for outpatient surgery performed on a Medicare patient? ✔✔RBRVs HIPAA requires the retention of health insurance claims and accounting records for a minimum of ____ years, unless state law specifies a longer period ✔✔ 6 The prevention of illness though vaccination occurs due to the formation of ✔✔Memory Cells Dr. Z ordered a CEA test for Mr. L, a 67 year old African American male patient. Dr. Z may be considering a dx of ✔✔cancer Which of the following cells produces antibodies? ✔✔plasma cells Each of the following conditions fall under the category of COPD EXCEPT ✔✔pneumonia
A toxic goiter has what distinguishing characteristic ✔✔thyroid hyperfunction Which of the following elements of negligence must be present in order to recover damages? ✔✔duty of care; breach of duty of care; suffered an injury; defendant's conduct caused the plaintiff harm As the director of HIT for Bayshore Hospital you are asked to provide sworn verbal testimony in a suit by a former patient. This testimony is ✔✔Deposition As the director of HIT for Bayshore Hospital you are asked to provide written answers to questions asked in a suit by a former patient. This is ✔✔Interrogatory As the director of HIT for Bayshore Hospital you are asked to provide written answers to questions asked in a suit by a former patient and asked to provide sworn verbal testimony as well. The phase of this lawsuit is ✔✔Discovery Which of the following claims of negligence fits into the category of res ipsa loqitur? ✔✔Leaving a foreign body inside a patient When a health care facility fails to invesetigate the qualifications of a physician hired to work as an independent contractor in the emergency room and is accused of negligence, the health care facility can be held liable under ✔✔corporate negligence
Electronically stored information, for example, the EHR, differs from paper-based information in Volume, variety of sources, and confidentitality but not ✔✔metadata Under traditional rules of evisence, a medical/health record is considered and is into evidence. ✔✔hearsay; inadmissable Elements of a contract are ✔✔offer/communication, price/consideration, acceptance is not an element of a contract ✔✔duty In which of the following circumstances would release of information without the patient's authorization be permissible? ✔✔Release to third party payers When conducting a study, you classify pain levels associated with a specific illness as: 01, none; 02 , little or minimal; 3 moderate; 04 heavy; 05, severe. These data are best described as ✔✔ordinal Which of the following interactions fits the definition of a patient encounter? P daw Dr. H during a scheduled office visit. Dr. H prescribed a new med. J called Dr. H with a question about her med. Dr. H retruned the call and answered J's question. L was seen by Dr. H in the ER adfter having a reaction to his meds. The pharmacy recevied telephone approval from Dr. H for a refil on F's meds. ✔✔P and L.
Which is true about the Privacy Act of 1974? ✔✔It applies to the Federal Govt. Mag looked up PHI on her ex-sister-in-law. A routine audit discovered the violation. Which statement is true under ARRA? ✔✔Mag cannot be prosecuted as a covered entity. Which statement is true when a family member can be provided PHI? ✔✔The family member is directly involved in the the care of the patient. Nick is developing an agreement that will be used between the hospital and the health care clearing house. This will require the two parties to protect the privacy of data exchanged and is called ✔✔A business associate agreement You have been given the task of destroying PHI stored on an old server. What method would you use? ✔✔Degaussing (magnets) Which of the following documents is subject to the HIPAA security rule? ✔✔Scanned op report stored on CD (security rule only applies to ePHI) Which of the following situations would require authorizations before disclosing PHI? ✔✔public health activities
A covered entity is ✔✔includes health care providers who perform specified actions electronically You have been asked to create a presentation on intentional and unintentional threats. What would you cite? ✔✔a patient SSN being used for a credit card applications. You will be choosing the type of encryption to be used for the new EHR. What are your choices? ✔✔symmetric and asymmetric Your system just crashed. You have established a site that holds computer processors but not data. This site can be converted to meet needs quickly. This is a ✔✔cold site Which of the following is a true statement about symmetric encryption? ✔✔Symmetric encryption assigns a secret key to data. HIPAA workforce security requires ✔✔that access to PHI be appropriate. Richard has asked to view his medical record. The record is stored off-site. How long does the facility have to provide his record to him? ✔✔60 days A data use agreement is required when ✔✔a limited data set is used What type of digital signature uses encryption. ✔✔digital signature
Critique the following statement? The EHR utilizes existing source systems to supply data ✔✔This is true because the EHR uses many source systems to populate the data The hospital is undergoing the development of an IS strategic plan. The part of the process where changes in the community, legislation, and other factors are monitored is called the ✔✔environmental scanning Upon final review of the RFP that is to be sent out to prospective vendors, you notice that there is content that should not be included in the operational requirement section. What should be deleted? ✔✔Data conversion You are interested in performing some data anaylsis on patients with cardiac problems. You have downloaded the data you need from the data warehouse into a smaller database. You are using a ✔✔DATA MART The admin has asked for a patient satisfaction database internally to be used to collect data that can be used to provide improved services. He does not want this to be a long process. Which of the following could speed this process? ✔✔Prototyping In selecting a messaging standard for use in a picture archival communication system (PACS) the best choice would be ✔✔DICOM (digital imaging communication in medicine)
Which is an example of EHR functionaltiy? ✔✔electronic communications Why would the database adminstrator add a foreign key to one of the tables? ✔✔to indicate that it is a primary key in another table Which application design is used in computer assisted coding (CAC) ✔✔natural language processing (NLP) You ROI system has part of the computing on the workstation and part on the file server. What type of technology is being used? ✔✔client server
