Patient care chapter 25: health records and health information management – Flashcards
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Documenting relevant patient information in the medical record
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Is not a function of a hospitals health information management department
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The prospective payment system is a payment system based on
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The diagnosis related group
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Joint commission on accreditation of health care organizations is an example of
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An organization that accredits hospitals and other health care institutions in the U.S.
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The chief complaint, included in a patients history, is a statement made bye the
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Patient
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The health insurance portability and accountability act of 1996 (HIPPA) legislation affects radiology and other hospital departments by its focus on
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Patient record confidentiality
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Patients telephone number
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Is not required to be included in a patients health record
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Criteria used in performance improvement activities must be all of the following ( clinically valid, written, generally acceptable to department staffs) except
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Diagnosis or procedure oriented
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Assessment of problems in performance improvement activities must be
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On going
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In making a correction to an entry in the paper health record, the documented should
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Line out the error, authenticate, insert correct information
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The organization ( chart order, forms) of a hospital patient record is determined by
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The hospitals own preference
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Apc
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Ambulatory payment classification
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Cpt
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Current procedural terminology
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Icd-10-cm
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International classification of diseases 9th edition clinical modification
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Drg
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Diagnosis related group
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Tjc
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The joint commission
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Pps
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Prospective payment system
