question

Recording of pertinent healthcare findings, interventions, and responses to treatment as a business record and form of communication among caregivers. Allows for the telling and re-telling of events.

answer

Documentation

question

Describes those principles, codes, beliefs, guidelines, and regulations that guide healthcare documentation. Dictates how healthcare providers should document the treatment and services within the health record. Are evaluated conformance with a generally accepted rule.

answer

Documentation Standards

question

health records that typically have the same basic documentation standards.

answer

EHR and paper-based

question

Documentation _______ have grown in complexity and detail over time. Focus on patient care quality, appropriate reimbursement, and the prevention of fraud and abuse.

answer

Standards

question

Insurance company or payers Government regulatory agencies Licensing boards Accrediting bodies Facility policies and procedures Medical staff bylaws

answer

Sources of Documentation Standards

question

Ensure complete health record and accurately reflects the treatment provided to the patient. Provide overall inherent level of acceptable quality. Drive appropriate reimbursement through accurate code capture.

answer

Goals of Documentation Standards

question

Standards governing the practice of medical staff members Voted on by the organized medical staff and the medical staff executive committee Approved by the facility's board of directors Used to enforce quality of care Licensure organization Accrediting and licensure organizations as well as federal and state regulatory agencies mandate the content of the bylaws will vary slightly from one organization to another

answer

Medical Staff Bylaws

question

Group of physicians and non-physician providers who have privileges to practice medicine at a particular healthcare organization. May or may not be employed by the healthcare organization. __________ are subject to the medical staff bylaws.

answer

Medical Staff

question

Specific services and procedures that the medical staff member is deemed qualified to perform, at a particular healthcare organization

answer

Medical Staff Privileges

question

Federal agency within the US Department of Health and Human Services(HHS). Operational of the Medicare program in collaboration with state governments.

answer

Centers for Medicare and Medicaid Services (CMS)

question

A voluntary process Periodical evaluation of the quality of the entity's work against pre-established written criteria Healthcare organizations measure their own compliance with standards Enhances the reputation of the organization in the eyes of the patient Differs by the type of program or service

answer

Accreditation

question

Must go through its own CMS review to obtain deemed status

answer

Accreditation Organization (AO)

question

Accredits wide variety of healthcare organizations. Continuously updates survey processes. Surveys clinical and operational components. Provides education to healthcare organizations related to compliance.

answer

Joint Commission

question

An official designation indicating that healthcare facility is in compliance with the Medicare Conditions of Participation.

answer

deemed status

question

Joint Commission Provides accreditation for:

answer

Ambulatory healthcare Behavioral health Critical access hospital Homecare Hospital Laboratory Nursing care centers Physician offices Office-based surgery centers

question

Legislation written and approved by a state legislature and then signed into law by the state's governor Addresses the documentation requirements for specific types of health records

answer

Statute

question

Supports revenue,supports testimony. Documents and data elements that a healthcare provider may include in response to legally permissible requests for patient information: Content varies from provider organization to another: May be hybrid record model: Defining the ______________ is difficult with health information exchanges (HIEs)

answer

Legal Health Record

question

Apply to all categories of health records. Every healthcare organization should have policies . Organized systematically to facilitate data retrieval and compilation. Only individuals authorized by the organization's policies should be allowed to enter documentation in the health record. Organizational policy or medical staff rules and regulations should specify who may receive and transcribe verbal physician's orders. Health record entries should be documented at the time the services they describe are rendered. Authors of entries should be clearly identified in the record. Only abbreviations and symbols approved by the organization or medical staff rules and regulations should be used in the health record. All entries in the health record should be permanent.

answer

General Documentation Guidelines

question

Any corrections or information added to the record by the patient should be inserted as _________.

answer

Addendum

question

All patient medical record entries must be legible, complete, dated, times, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided consistent with hospital policies and procedures.

answer

CMS documentation requirements

question

The process of identifying the source or health record entries by attaching a hand-written signature, the author's initials, or an electronic signature. CMS requires controls to prevent any changes from being made to the health record after the entries have been authenticated

answer

Authentication

question

When a physician or other care provider cannot authenticate an entry that he or she cannot review.

answer

Auto-Authentication

question

Documentation by Setting; Health record information consists of two types regardless of setting

answer

Clinical Administrative-patient's demographics

question

It is generated when a patient is provided with room, board, and continuous general nursing care in an area of an acute-care facility. Within the inpatient care services continuum, there are three major records types: Medical/Surgical Obstetric Newborn

answer

Inpatient Health Record

question

The ____________ health record is found in a variety of settings: Inpatient care units Long-term care facilities Home health Surgical centers Ambulatory care units Health record documentation will pertain to adult patients with various acute and active disease processes or injuries.

answer

Medical/Surgical

question

Nine components: Medical history-history of present illness,personal ,family history, travel history. Physical exam-vital signs etc. Diagnosis and therapeutic procedure orders-all drs order. Clinical observations. Diagnostic and therapeutic procedure reports-lab tests etc. Procedure and surgical documentation-procedure note. Consultation reports-drs opinion,requested by the provider. Discharge summary- Patient instructions and transfer records-instructions when you go home,transfer docs.

answer

Basic Acute Care Content

question

Basic Acute Care Content; Insurance payer information. Insurance policy holder information. Patient's relationship to the insurance policy holder. Insurance policy number.

answer

Patient account information

question

Some health records have unique requirements because of the specialized services provided: Obstetric Newborn

answer

Special Health Records

question

Medical history including history of abuse or neglect and sexual practices Periodic routine laboratory testing Additional laboratory testing for high-risk groups such as tuberculosis skin testing and testing for sexually transmitted diseases

answer

Obstetric/Gynecology

question

Must stabilize patient in emergency Prohibits healthcare providers from refusing to treat patients or delaying treatment due to inability to pay

answer

EMTALA (Emergency Medical Treatment and Active Labor Act

question

To ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient

answer

overall goal of documentation standards

question

A hospital that participates in the medicare and medicaid program must follow:

answer

conditions of participation

question

When defining its legal health record, a healthcare provider organization must do which of the following?

answer

assess the legal environment

question

Which of the following is the health record component that addresses the patient's current complaints and symptoms and lists the patient's past medical, personal and family history?

answer

medical history

question

general documentation guidelines apply to:

answer

all categories of healthcare records

question

A patient's gender,phone number,next of kin and insurance policy holder information would be considered what kind of data?

answer

administrative data

question

Patient history questionnaires, problem lists, diagnostic tests results, and immunization records are commonly found in which type of record?

answer

ambulatory record

question

What type of health records may contain family and caregiver input?

answer

Behavioral health records

question

The ambulatory surgery record contains information most similar to which of the following?

answer

Hospital operatives record

question

Which group focuses solely on accreditation of rehabilitation programs and services?

answer

CARF (Commission on Accreditation of Rehabilitation Facilities)

question

Which type of health record contains information about the means by which the patient arrived at the healthcare setting and documentation of care provided to stabilized patient?

answer

Emergency care

question

A patient's registration forms, personal property list, (resident assessment instrument)RAI, care plan, and discharge or transfer documentation would be found most frequently in which type of health record?

answer

Long-term care

question

Which of the following would not be found in a physical exam?

answer

General condition

question

An attending physician requests the advice of a second physician who then reviews the health record and examines the patient. The second physician records his or her evaluation in what type of report?

answer

Consultation

question

Written or spoken permission to proceed with care is classified as?

answer

Expressed consent

question

Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps.

answer

care plan

question

Reports that provide information on tissue removed during a procedure.

answer

Pathology report

question

A growth and development record may be found in what type of record?

answer

pediatric

question

The subjective, objective, assessment, plan (SOAP) method came from the:

answer

Problem- oriented health record

question

Which of the following electronic record technological capabilities would allow paper-based health records to be incorporated into a patient's EHR?

answer

Documentation-imaging technology

question

The problem list is part of which of the following?

answer

Problem-oriented health record

question

The paper health record has been scanned and is now available digitally. What is this known as?

answer

imaging

question

Nursing documentation within the health record will be:

answer

Both subjective and objective

question

(T/F) Health record entries should be documented at the time the services they described are rendered.

answer

true

question

Only individuals authorized by the organization's policies should be allowed to enter documentation in the health record.

answer

true

question

Auto-authentication is the preferred method for authentication.

answer

false

question

When an error is made, the erroneous information can be obliterated.

answer

false

question

Many services such as surgery, infusions, and other diagnostic procedures that once required an overnight hospital stay for the patient, no longer requires that level of care.

answer

true

question

CMS requires that healthcare providers inform their patients about general patient rights afforded to them.

answer

true

question

Healthcare provider organizations normally have patients sign an acknowledgement acknowledging that the healthcare provider organization is not responsible for the loss and damage to the patient's valuable.

answer

true

question

Payers and the government are not concerned with how a physician documents in a health record.

answer

false

question

Only physicians document in the health record.

answer

false

question

HIM professionals document in the health record.

answer

false

question

Management of health record information is a fundamental component of information governance.

answer

true

question

The emergency department record itself is sometimes incorporated within the inpatient health record and at other times, is kept separately

answer

true

question

Includes: Arrival time Means of arrival Name of person bring patient to ED Disposition of patient Condition of patient on discharge

answer

Emergency Department Record

question

contain: Registration forms Problem lists Medication lists Patient history questionnaires History and physicals Progress notes Results of consultations Diagnostic test results Miscellaneous flow sheets (for example, pediatric growth charts and immunization records and specialty-specific flow sheets) Copies of records of previous hospitalizations or treatment by other healthcare practitioners Correspondence Consents to disclose information Advance directives

answer

Ambulatory Record

question

Documentation of surgery Records call to patient 24-48 hours after discharge

answer

Ambulatory Surgery Record

question

Documentation of tests and treatments performed Includes lab, radiology, pharmacy, and more

answer

Ancillary Departments Record

question

Contains Ongoing assessments Resident Assessment Instrument Minimum Data Set Treatment plan Typical health record documentation

answer

Long Term Care

question

Documentation varies based on inpatient or outpatient setting but includes: Diagnosis of disability and functional diagnosis. Rehabilitation problems, goals, and prognosis. Typical health record documentation.

answer

Rehabilitation

question

Health Information Media

answer

Paper Hybrid Electronic

question

Source-orientated health record Universal chart order Integrated health record Problem-orientated medical record Subjective, Objective, Assessment, Plan (SOAP)

answer

Paper Health Record Format

question

Capture, digitize, integrate, store, and retrieve paper-based health record documentation; Organizes and assembles the paper-based health record documentation, and controls the versioning, access, and search capabilities of the documentation.

answer

Web-Based Document Imaging

question

Nurses Documentation varies by licensing and regulatory requirements, setting, and internal policy and procedures

answer

true

question

Documentation of care in physician office includes: Medical history Family history Social history Vital signs Chief complaint Progress notes Allergies Medication list History of present illness Review of systems-the dr's physical exam Assessment and diagnosis Plan of treatment

answer

Physician Office Record

question

Contains: Treatment plan; Social worker's assessment and documentation of the family or home environment and community services available; Psychiatric evaluation; Typical health record content.

answer

Behavioral Health

question

Many follow treatment plan developed by the patient's physician or a therapist or technologist ; Documents treatment and patient's response

answer

Allied Health Professionals

question

Plays vital and different roles in the overall governance of health record information. Manages many aspects of the health record and its content. Roles are more information technology (IT) focused.

answer

HIM

question

The health record post patient discharge is kept in reverse chronological order called _______.

answer

Universal chart order

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