Chapter 1 RHIT Study Guide question n answers graded A+ 2023

Chapter 1 RHIT Study GuideFor continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the - correct answer problem list. In an acute care hospital, a complete history and physical may not be required for a new admission when - correct answer a legible copy of a current H&P performed in the attending physician's office is available. As supervisor of the cancer registry, you report the registry's annual caseload to administration. The most efficient way to retrieve this information would be to use - correct answer accession register. You are the Director of Coding and Billing at a large group practice. The Practice Manager stops by your office on his way to a planning meeting to ask about the timeline for complying with HITECH requirements to adopt meaningful use EHR technology. You reply that the incentives began in 2011 and ended in 2014. You remind him that by 2015, sanctions for noncompliance began to appear in the form of - correct answer downward adjustments to Medicare reimbursement. Ultimate responsibility for the quality and completion of entries in patient health records belongs to the - correct answer attending physician. A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the history and physical is true in this situation? Completion and charting of the H&P indicates - correct answer noncompliance with Joint Commission standards One record documentation requirement shared by BOTH acute care and emergency departments is - correct answer patient's condition on discharge In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the - correct answer Federal Register. Your committee is charged with developing procedures for the Health Information Services staff of a new home health agency. You recommend that the staff routinely check to verify that a summary on each patient is provided to the attending physician so that he or she can review, update, and recertify the patient as appropriate. The time frame for requiring this summary is at least every - correct answer 60 days During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day 4 of hospitalization there was one missed dose of insulin. What type of review is this clerk performing? - correct answer qualitative review As the Chair of the Forms Committee at your hospital, you are helping to design a template for house staff members to use while collecting information for the history and physical. When asked to explain how "review of systems" differs from "physical exam," you explain that the review of systems is used to document - correct answer subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility's - correct answer disease index. Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that - correct answer evidence cannot be provided that the physician actually reviewed and approved each report. As the Coding Supervisor, your job description includes working with agents who have been charged with detecting and correcting overpayments made to your hospital in the Medicare Fee for Service program. You will need to develop a professional relationship with - correct answer recovery audit contractors. Based on the following documentation in an acute care record, where would you expect this excerpt to appear?