Patient care chapter 25: health records and health information management

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

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