Health Data Content and Standards Final Quiz (ASSURED A)

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Health Data Content and Standards Final Quiz Which of the following is a form or view that is typically seen in the health record of a long-term care patient but is rarely seen in records of acute ... care patients?  pharmacy consultation  medical consultation  physical exam  emergency record CORRECT Pharmacy consults are required for elderly patients who typically take multiple medications. These consults review for potential drug interactions and/or discrepancies in medications given and those ordered. The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely include checking for documentation regarding  whether a postoperative infection occurred and how it was treated.  the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed.  the quality of follow-up care.  whether the severity of illness and/or intensity of service warranted acute level care. CORRECT "Whether a postoperative infection occurred and how it was treated" represents an appropriate job for the infection control officer. "The quality of follow-up care" represents the clinical care evaluation process, rather than the review of quality documentation. "Whether the severity of illness and/or intensity of service warranted acute level care" is a function of the utilization review program. The correct answer is "the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed." For inpatients, the first data item collected of a clinical nature is usually  review of systems.  expected payer.  admitting diagnosis.  principal diagnosis. CORRECT Clinical data include all health care information collected during a patient's episode of care. During the registration or intake process, the admitting diagnosis, provided by the attending physician, is entered on the face sheet. If the patient is admitted through the ED, the chief complaint listed on the ED record is usually the first clinical data collected. The principal diagnosis is often not known until after diagnostic tests are conducted. Demographic data are not clinical in nature. The review of systems is collected during the history and physical, which is typically done after admission to the hospital. You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility's  disease index.  patient index.  number control index.  physicians' index. CORRECT The major sources of case findings for cancer registry programs are the pathology department, the disease index, and the logs of patients treated in radiology and other outpatient departments. The number index identifies new health record numbers and the patients to whom they were assigned. The physicians' index identifies all patients treated by each doctor. The patient index links each patient treated in a facility with the health number under which the clinical information can be located. You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility's  disease index.  patient index.  number control index.  physicians' index. CORRECT The major sources of case findings for cancer registry programs are the pathology department, the disease index, and the logs of patients treated in radiology and other outpatient departments. The number index identifies new health record numbers and the patients to whom they were assigned. The physicians' index identifies all patients treated by each doctor. The patient index links each patient treated in a facility with the health number under which the clinical information can be located. As the chair of a Forms Review Committee, you need to track the field name of a particular data field and the security levels applicable to that field. Your best source for this information would be the  facility's data dictionary.  glossary of health care terms.  MDS.  UHDDS. CORRECT "MDS" and "UHDDS" are types of data sets for collecting data in long-term (MDS) and acute care (UHDDS) facilities. A data dictionary should include security levels for each field as well as definitions for all entities [Show More]

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