Rhit exam stuvia - Study guides, Class notes & Summaries

Which of the following is a characteristic of breach notification? - ANSWER It applies when one person's PHI is breached A PI Team is concerned with the time it is taking for patients to get through the registration process. To better understand the causes or reasons for the delay in this process the PI Team would like to gather observational data. What data collection tool would be appropriate for this team to develop for their observation data? - ANSWER Check sheet The process that is f...

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...

Displays before and after data. It is used to identify the strengths and weaknesses of an activity is called? - ANSWER Radar Chart Every employee receives direction and instructions from only one boss? - ANSWER Unity of command All workers are aligned in their efforts toward a single outcome is called? - ANSWER Unity of direction Employees should receive fair pay for work? - ANSWER Remuneration Everyone is clearly included in the chain of command and line of authority from top to bot...

American College of Surgeons - ANSWER inaugerated the hospital standardization movement continuum of care - ANSWER places emphasis on treating individual patients at the level of care required by their course of treatment and extends from their primary care providers to specialists and ancillary providers managed care organizations - ANSWER a type of healthcare organization that delivers medical care and manages all aspects of patient care or the payment for care by limiting providers of 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...

H.I.M has been recognized as an allied Health profession since: - ANSWER 1928 The hospital standardization movement was inaugurated by the : - ANSWER American College of Surgeons The new model of H.I.M practice is: - ANSWER Information based What evolving role oversees the process that begins at the time of documentation through billing? - ANSWER Revenue cycle management The organization that accredits H.I.M programs is: - ANSWER C.A.H.I.I.M What evolving role assesses quality in ...

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...

(113) If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following? A) Length of the lesion as described in the pathology report B) Dimension of the specimen submitted as described in the pathology report C) Width times the length of the lesion as described in the operative report D) Diameter of the lesion as well as the margins excised as described in the operative report - ANSWER D) D...

Database - ANSWER A collection of data organized for rapid search and retrieval is called a Sharing of patient information between providers - ANSWER Health Information Exchange provides Human populations - ANSWER Demographics is the study of statistical information and Provider query form - ANSWER The main communication for between physicians and clinical documentation improvement programs is Clinical Data - ANSWER Which of the following would be used to locate a patient's health i...

What best describes data comprehensiveness - ANSWER Data that includes all required elements "Blood pressure adequately controlled." In which part of a problem oriented health record progress note would this be written? - ANSWER Assessment What makes up an assessment - ANSWER Professional conclusions reached from evaluation of the subjective or objective information. The attending physician is responsible for what type of acute-care documentation? - ANSWER Discharge Summary A conci...