Example of Point-of-Service care & documentation - ACCURATE ANSWERS 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? - ACCURATE ANSWERS Doc requir...
Example of Point-of-Service care & documentation - ACCURATE
ANSWERS✔✔ 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? - ACCURATE
ANSWERS✔✔ 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? - ACCURATE
ANSWERS✔✔ 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? - ACCURATE
ANSWERS✔✔ LTC
TJC compliance rate for Delinquent records is - ACCURATE
ANSWERS✔✔ Under 50%
Who is responsible for accurateness & completeness of pts MRs? -
ACCURATE ANSWERS✔✔ MDs (not HIM director, RNs or other
administrative positions)
,Dictated Operative report is due - ACCURATE ANSWERS✔✔
Immediately after surgery. If transcription service is down, the surgeon
has to write a detailed OP note
One of Utilization Review functions - ACCURATE ANSWERS✔✔
Compare severity of illness & Intensity of service warrant acute care
level
One of Clinical Care Eval processes - ACCURATE ANSWERS✔✔
Quality of follow-up care
Tumor registry cases accession numbers - ACCURATE ANSWERS✔✔
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? - ACCURATE ANSWERS✔✔ Permanent
log of all cases entered in a database (used in Tumor registry)
What is R-ADT system? - ACCURATE ANSWERS✔✔ Registration-
Admission, DC & Transfer system. Best to use for tracking pts who have
been transferred to a specialty unit
Difference between ROS & H&P - ACCURATE ANSWERS✔✔ 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 - ACCURATE
ANSWERS✔✔ # of delinquent records is >50% AND Delinquent
records missing H&P >2% of the Average monthly DCs
Integrated vs Separated Progress notes - ACCURATE ANSWERS✔✔
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 - ACCURATE
ANSWERS✔✔ 1) Interdisciplinary pt care plan
2) DC summary
3) Transfer records
Ambulatory care providers rely on documentation found in -
ACCURATE ANSWERS✔✔ Problem list
Core measures quality indicators for compliance with HCQIP (Medicare
Health Care Quality Improvement Program) - ACCURATE
ANSWERS✔✔ 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
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