In preparation for an HER, you are conducting a total facility inventory of all forms currently used.
You must name each form for bar coding and indexing into a document management system. The
unnamed document in front of you includes a microscopic description of tissue excised during
surgery. The document type you are most likely to give to this form is
B
Patient data collection requirements vary according to health care setting. A data element you would
expect to be collected in the MDS, but not in the UHDDS would be
B
A good first step toward protecting the security of data contained in a health information computer
system would be to
B
In the number “99-0001” listed in a tumor registry accession register, what does the prefix “99”
represent?
B
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
C
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
Joint Commission does not approve of auto authentication of entries in a health record. The primary
objection to this practice is that
B
As part of quality improvement study you have been asked to provide information on the menstrual
history, number of pregnancies, and number of living children on each OB patient from a stack of old
obstetrical records the best place in the record to locate this information is the
A
As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an
updated history and physical for one of her recent admissions. Dr. Crossman pages through the
medical record to a copy of an H&P performed in her office a week before admission. You tell Dr.
Crossman.
C
As a new CTR, you are interested in identifying every reportable case of cancer from the previous
year. A key resource will be the facility’s
A
Joint Comission requires the attending physician to countersign health record documentation that is
entered by
A
The minimum length of time for retaining original medical records is primarily governed by
C
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 rmeasures might be utilized to govern the use of
D
Discharge summary documentation must include
C
The performance of ongoing record reviews is an important tool is ensuring data quality through
accurate health records. These reviews evaluate
D