RHIT

The Medical Record Committee is assessing various strategies to improve documentation in the health record. Concerns have been raised that current documentation practices may be insufficient to support diagnoses or reflect the progress and clinical findings in patient care. Which of the following would be the best first step to help improve physician documentation? (Ans- Determine the type and volume of documentation problems This type of healthcare organization review is conducted at the r...

A health record technician has been asked to review the discharge patient abstracting module of a proposed new 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 Medicaid inpatients in an acute-care hospital? (Ans- UHDDS Standardizing medical terminology to avoid differences in naming various health conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and...

Which of the following data sets would be most helpful in developing a hospital trauma data registry? a. DEEDS b. MDS c. OASIS d. UACDS (Ans- a. DEEDS In 1997, the Centers for Disease Control and Prevention (CDC), through its National Center for Injury Prevention and Control (NCIPC), published a data set called Data Elements for Emergency Department Systems (DEEDS). The purpose of this data set is to support the uniform collection of data in hospital-based emergency departments and to...

Based on a productivity log, a coder completed 23 charts during a 7.5-hour workday. The performance standard is 4 charts per hour. How many charts did he code per hour? Round to the nearest whole number. a. 2.06 b. 4.1 c. 23 d. 3 (Ans- d. 3 Work measurement is based on assessment of internal data collected on actual work performed within the organization and the calculation of time it takes to do the work. Employees log what they do and the time spent on tasks in units of work receive...

Alphabetic filing method (Ans- Used for paper records, no unique identifiers, not commonly used as it takes up storage space. Looks like: John Smith Numeric filing method (Ans- Medical record number, straight filing. Looks like: 123456 Terminal Digit (Ans- Separates the medical record number into chunks. Looks like: = Primary Unit 34= Secondary Unit 56= Tertiary Unit Middle Digit (Ans- Same as terminal digit but the middle number is the Primary unit. Looks like: = Primary Unit ...