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In the past, the Joint Commission standards focused on promoting the use of a facility approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to - use of prohibited or "dangerous" abbreviations ...

A health record technician has been asked to review the discharge patient abstracting module of a proposed new electronic health record (EHR). Which of the following data sets would the technician consult to ensure the system collects all federally required discharge data elements for Medicare and...

(113) If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following? A) Length of the lesion as described in the pathology report B) Dimension of the specimen submitted as described in the path...

One important element of data quality is security in preventing unauthorized access, corruption, misuse, and loss of data. Technical and procedural methods will be used with the CPR to control and manage confidential information. An example of a of protecting data thru a procedural method is: Con...

The RHIT supervisor for the filing and retrieval section of Community Clinic is developing a staffing schedule for the year. The clinic is open 260 days per year and has an average of 600 clinic visits per day. The standard for filing records is 60 records per hour. The standard for retrieval of r...

Who owns the health record? a. Patient b. Provider who generated the information c. Insurance company who paid for the care recorded in the record d. No one - B Community Hospital is terminating its business associate relationship with a medical transcription company. The transcription company...

Dr. Reed tried to explain wound care to Mr. Baker prior to discharge, but Baker (who is 104 and moderately senile) just could not seem to understand or remember what the doctor said. Mr. Baker's daughter was with him, so Dr. Reed explained Mr. Baker's aftercare to his daughter. Dr. Reed should ...

OASIS data are used to assess the ___ of home health services. - Outcome A statement or guideline that directs decision making or behavior is called a: - Policy Examples of high-risk billing practices that create compliance risks for healthcare organizations include all of the following, except: ...

Who are the primary users of the health record? - Patient Care Providers Those individuals who enter, verify, correct, analyze or obtain information from the record, either directly or indirectly through and intermediary are known as? - Users of Health Records Special software that aids formattin...

Which of the following data is an example of secondary data collected from a structured query? a. Lab results dated October 1 b. ICD-10-CM code E10 in the diagnostic index c. Chest X-ray record at Grove Diagnostic Center d. Hospital record for labor and delivery - b. ICD-10-CM code E10 in the di...

In healthcare, data sets serve two purposes. The first is to identify data elements to be collected about each patient. The second is to: a. Provide uniform data definitions b. Guide efforts toward computerization c. Determine statistical formulas d. Provide a research database - a. Provide uni...