*NURSING > EXAM > Health Computing - RHIT Exam Prep 2022 QUESTIONS AND ANSWERS (All)

Health Computing - RHIT Exam Prep 2022 QUESTIONS AND ANSWERS

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Example of Point-of-Service care & documentation - 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? - 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? - 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? - LTC TJC compliance rate for Delinquent records is - Under 50% Who is responsible for accurateness & completeness of pts MRs? - MDs (not HIM director, RNs or other administrative positions) Dictated Operative report is due - Immediately after surgery. If transcription service is down, the surgeon has to write a detailed OP note One of Utilization Review functions - Compare severity of illness & Intensity of service warrant acute care level One of Clinical Care Eval processes - Quality of follow-up care Tumor registry cases accession numbers - 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? - Permanent log of all cases entered in a database (used in Tumor registry) What is R-ADT system? - Registration-Admission, DC & Transfer system. Best to use for tracking pts who have been transferred to a specialty unit Difference between ROS & H&P - 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) [Show More]

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