What it uhdds - Study guides, Class notes & Summaries

In preparation for EHR, 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 managment system. THe unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you most likely to give to this form is A. recovery room record B. pathology report C. operative report D. discharge summary - B. pathology report (C and D) although a gross description of...

CCA Exam Preparation All Domains Actual Questions and Answers During an audit of health records, the HIM director finds that transcribed reports are being changed by the author up to a week after initial transcription. The director is concerned that changes occurring this long after transcription jeopardize the legal principle that documentation must occur near the time of the event. To remedy this situation, the HIM director should recommend which of the following? - Correct Answer-Develo...

CCS Exam Prep Questions and Answers Graded A+ 7 yo pt admitted to ED for tx of shortness of breath and given epinephrine and nebulizer tx. Shortness of breath and wheezing are unabated following tx, so what dx should be suspected? Asthma with status asthmaticus Pt admitted with high temp, lethargy, hypotension, tachycardia, oliguria, elevated WBC, and has more than 100K organisms of E. coli per cc of urine. Attending phys documents "urosepsis", so what is the next step for the coder? ...

(1) A critical early step in designing an EHR is to develop a(n) ________in which the characteristics of each data element are defined. A) Accreditation manual B) Core content C) Continuity of care record D) Data dictionary - ANSWER-D) Data dictionary (2) Once hospital discharge abstract systems were developed and their ability to provide comparative data to hospitals was established, it became necessary to develop: A) Data sets B) Data elements C) Electronic data interchange D)...

Relias (5-19), Exam Questions and answers, VERIFIED. If two or more procedures meet the definition, the principal procedure is the one that relates to the principal diagnosis. - -true The coding supervisor should instruct coding staff on the types of procedures that should be coded and reported for the facility. - -true. Procedures performed on the skin with the use of topical anesthesia carry an anesthetic risk. - -false. The UHDDS definition for a significant procedure is one that is...

Example of Point-of-Service care & documentation answer is: - 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 is: - 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 is: - No guarantee that MD ...

Once hospital discharge abstract systems were developed and their ability to provide comparative data to hospitals was established, it became necessary to develop: Data sets Data elements Electronic data interchange Bills of mortality - ANSWER-Data Set In long-term care, the resident's care plan is based on data collected in the? UHDDS OASIS MDS HEDIS - ANSWER-MDS (Minimum Data Set) Which of the following statements describes alphabetical filing? File the record alphabe...

mock RHIT exam 2Which of the following is true about the Joint Commission's "Do Not Use" abbreviation list? a. It applies to handwritten orders and medication-related documentation (including free-text computer entry) or on pre-printed forms. b. It applies to only medication-related orders c. It applies to all documentation in the health record d. It applies to only preprinted forms - correct answer a. It applies to handwritten orders and medication-related documentation (includin...

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 Medicaid inpatients in an acute-care hospital? a. CARF b. DEEDS c. UACDS d. UHDDS - ANSWER d. UHDDS (Uniform Hospital Discharge Data Set) The Uniform Hospital Discharge Data Set (UHDDS) data c...

Health record tech is asked to review discharge pt abstracting module of proposed new EHR, so what would tech consult to ensure system collects all fed req discharge data elements for Medicare, Medicaid inpts in acute-care hosp? - ANSWER Uniform Hospital Discharge Data Set (UHDDS) Outpt clinic reviews functionality of EHR it is considering purchasing, so what should the clinic consult that ensure all fed recommended data elements for Medicare, Medicaid outpts are collected by system? - ANSWER...