Example of Point-of-Service care & documentation
RN using a terminal to record vital signs. There's a difference between computer application in health care and clinical application of computers
What do I find in Medical Staff Rules & Regulations?
Doc requirements for pts' records, time frame fo...
Health Computing - RHIT Exam Prep (complete 2022
solution guide)
Example of Point-of-Service care & documentation
RN using a terminal to record vital signs. There's a difference
between computer application in health care and clinical
application of computers
What do I find in Medical Staff Rules & Regulations?
Doc requirements for pts' records, time frame for completion of
MRs, penalties for failure to comply C these requirements
Auto authentication. Why doesn't TJC approve it?
No guarantee that MD actually reviewed the MR & did sign it
electronically. Some facilities do use auto athentication
In what setting Interdisciplinary plan of care is used?
LTC
TJC compliance rate for Delinquent records is
Under 50%
Who is responsible for accurateness & completeness of pts
MRs?
MDs (not HIM director, RNs or other administrative positions)
Dictated Operative report is due
Immediately after surgery. If transcription service is down, the
surgeon has to write a detailed OP note
One of Utilization Review functions
Compare severity of illness & Intensity of service warrant acute
care level
One of Clinical Care Eval processes
Quality of follow-up care
Tumor registry cases accession numbers
,Each case in Tumor registry is assigned a unique accession
number. Ex: 10-001 (10- year the case was entered in a
database, 001 - case #1)
What is accession register?
Permanent log of all cases entered in a database (used in Tumor
registry)
What is R-ADT system?
Registration-Admission, DC & Transfer system. Best to use for
tracking pts who have been transferred to a specialty unit
Difference between ROS & H&P
1) Review of Systems - record of subjective Sx that a pt may
have forgotten to mention
2) H&P - record of Objective Sx MD is observing & other info
(social Hx, Hx of present illness)
Recommendation for improvement from TJC
# of delinquent records is >50% AND Delinquent records
missing H&P >2% of the Average monthly DCs
Integrated vs Separated Progress notes
Integrated - all providers from every discipline record progress
notes sequentially on the same form
vs
Separated - every discipline has its own designated form to
record their Progress notes
LTC pt care plans rely on documentation found in
1) Interdisciplinary pt care plan
2) DC summary
3) Transfer records
Ambulatory care providers rely on documentation found in
Problem list
, Core measures quality indicators for compliance with HCQIP
(Medicare Health Care Quality Improvement Program)
MI - pt is DC'd on ASA, beta blockers or other heart Rxs
Stroke - pt is DC'd on an anti-thrombotic
Pneumonia - pt had blood culture before 1st Abx started
Regional health information organizations
Support health information exchange within a geographic region
One essential item on Physical exam
General appearance as assessed by MD (Chief complaint, ROS
& Family Hx - medical Hx provided by the pt)
Elements of which data set do I collect if I'm a trauma registrar?
DEEDs (Data Elements for EDs) - recommended data set for
hospital-based EDs
Data set for Acute Care hospitals
UHDDS (Uniform Hospital Data Set) - required data set for
Acute Care hospitals
Data set for LTC
MDS (Minimum Data Set) - required data set for LTCs
ORYX
An initiative of TJC that implements 5 core measures to improve
safety and quality of health care.
5 core measures of ORYX
CHF. AMI. Pneumonia (CAP). Each has requirements, e.g. ASA
at arrival & DC, beta-blockers, blood culture, smoking cessation
advice, etc. ORYX has more core measure sets. A hospital
chooses the set according to the type of pts it treats (can be one
core & rest non-core)
Quantitative vs Qualitative analysis of MRs
Quantitative - check presence or absence of necessary sigs,
reports
vs
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller joynjoki63. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $10.49. You're not tied to anything after your purchase.
