Example of Point-of-Service care & documentation - Answer 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? - Answer Doc requirements for pts...
RHIT Study Guide Exam And Correct
Answers.
Example of Point-of-Service care & documentation - Answer 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? - Answer 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? - Answer 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? - Answer LTC
TJC compliance rate for Delinquent records is - Answer Under 50%
Who is responsible for accurateness & completeness of pts MRs? - Answer MDs (not HIM director, RNs
or other administrative positions)
Dictated Operative report is due - Answer Immediately after surgery. If transcription service is down,
the surgeon has to write a detailed OP note
One of Utilization Review functions - Answer Compare severity of illness & Intensity of service warrant
acute care level
One of Clinical Care Eval processes - Answer Quality of follow-up care
Tumor registry cases accession numbers - Answer 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? - Answer Permanent log of all cases entered in a database (used in Tumor
registry)
What is R-ADT system? - Answer Registration-Admission, DC & Transfer system. Best to use for tracking
pts who have been transferred to a specialty unit
Difference between ROS & H&P - Answer 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 - Answer # of delinquent records is >50% AND Delinquent
records missing H&P >2% of the Average monthly DCs
Integrated vs Separated Progress notes - Answer 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 - Answer 1) Interdisciplinary pt care plan
2) DC summary
3) Transfer records
Ambulatory care providers rely on documentation found in - Answer Problem list
Core measures quality indicators for compliance with HCQIP (Medicare Health Care Quality
Improvement Program) - Answer 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 - Answer Support health information exchange within a
geographic region
,One essential item on Physical exam - Answer 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? - Answer DEEDs (Data Elements for
EDs) - recommended data set for hospital-based EDs
Data set for Acute Care hospitals - Answer UHDDS (Uniform Hospital Data Set) - required data set for
Acute Care hospitals
Data set for LTC - Answer MDS (Minimum Data Set) - required data set for LTCs
ORYX - Answer An initiative of TJC that implements 5 core measures to improve safety and quality of
health care.
5 core measures of ORYX - Answer 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 - Answer Quantitative - check presence or absence of
necessary sigs, reports
vs
Qualitative - check documentation consistency, e.g. compare pt's Rx profile to MAR. Quality of
documentation NOT clinical care
Index with Unique Identifier codes - Answer Physician index - not real MDs name, but codes. To protect
MDs identity
POMR - Answer Problem Oriented MR. Helps index documentation throughout MR
H&P time standard to meet TJC & CoP requirements - Answer 24 hrs after admission or prior to surgery
, DC summary records - Answer Significant findings during hospitalization
Time frame and copies of recent H&P per TJC - Answer Copies of recent H&P done in MD's office is
allowed in lieu of admission H&P as long as the interval note (interval changes) are present upon
admission
When can Interval note replace H&P upon admission? - Answer 1) If pt is re-admitted within 30 days
for the same problem & copy of recent H&P is available;
2) If copy of recent H&P done in MD's office is available upon admission
Indices in hospital - Answer 1) MPI - cross-reference of pt's name & MR number;
2) Disease index - a listing in diagnostic code number order (I can use it to get stats on # of a Dz cases);
3) Physician index - a listing of cases in order by MD's name or number;
4) Operation index - a listing of operations performed
Most serious delinquencies - Answer 1) H&P;
2) Operative report;
Formal release of pt from hospital is - Answer DC order. If DC order is missing - pt is assumed to leave
AMA
Who can accept VOs? - Answer Persons designated by hospital's P&Ps and State & Federal laws
When is problem list required? - Answer On 3rd visit
RHIO - Answer Regional Health Information Organization - network allowing providers to access pts
MRs
Info on MR supplied by a pt - Answer Health Hx, CC & ROS - all subjective
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