A new health information management (HIM) director has been asked by the hospital CIO to ensure data content standards are identified, understood, implemented, and managed for the hospital's EHR system. Which of the following should the HIM director's first step in carrying out this responsibility?
Standardizing medical terminology to avoid differences in naming various health conditions and procedures, (such as the synonyms bunionectomy, McBride procedure and repair of hallux valgus) is one purpose of:
At admission, Mrs. Smith's date of birth is recorded as 3/25/1948. An audit of the EHR discovers that the numbers in the date of birth are transposed in reports. This situation reflects a problem in:
Identify the documentation that records the attending physician's assessment of the patient's current health status:
Which of the following is a key characteristic of the problem-oriented health record?
A health record technician has been asked to review the discharge patient abstracting moduled of a proposed new EHR. What data set 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 health data analyst has been asked to compile a report of the percentage of patients who had a baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical reports in the health record would the health data analyst need to consult in order to prepare the report?
Which of the following is considered the authoritative resource in locating a health record?
A family practitioner requests the opinion of a physician specialist who reviews the patient's health record and examines the patient. In what type of report would the physician specialist record findings, impressions, and recommendations?
The MPI manager has identified a pattern of duplicate health numbers from the specimen processing area of the hospital. The MPI manager merged the patient information and corrected the duplicates in the patient information system. After this merging process, which department should the MPI manager notify to correct the source system data?
What type of analysis compares omitted clinical information received from external providers with the needed clinical information to make a correct diagnosis?
To comply with Joint Commission standards, the HIM director wants to ensure the history and physical examinations are documented in the patient's health record no later than 24 hours after admission. Which of the following would be the best way to ensure the completeness of the health record?
The HIM director is having difficulty with the emergency services on-call physicians completing their health records. Currently 3 deficiency notices are sent to the physicians through the EHR system. Which of the following would be the best first step in trying to rectify the situation?
Creekside Care, skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to become certified for these programs?
A health record with deficiencies that is not completed within the timeframe specified in the medical staff rules and regulations is called a(n):