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CCS Exam Questions and answers, 100% Accurate, Question Bank rated A+. For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the docum ... entation found in the interdisciplinary patient care plan. discharge summary. transfer record.For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the interdisciplinary patient care plan. problem list. discharge summary. transfer record. - ✔✔- Discharge summary documentation must include correct codes for significant procedures. a note from social services or discharge planning. significant findings during hospitalization. a detailed history of the patient. - ✔✔-significant findings during hospitalization. Some reference to the patient's history may be found in the discharge summary but not a detailed history. The attending physician rather than a social worker records the discharge summary. Procedure codes are usually recorded on a different form in the record. In preparation for an EHR, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is operative report. discharge summary. pathology report. recovery room record. - ✔✔-pathology report. Although a gross description of tissue removed may be mentioned on the operative note or discharge summary, only the pathology report will contain a microscopic description. 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. physicians' index. number control index. patient index. - ✔✔-disease index. 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. Joint Commission does not approve auto authentication of entries in a health record. The primary objection to this practice is that it is too easy to delegate use of computer passwords. electronic signatures are not acceptable in every state. evidence cannot be provided that the physician actually reviewed and approved each report. tampering too often occurs with this method of authentication. - ✔✔-evidence cannot be provided that the physician actually reviewed and approved each report Auto authentication is a policy adopted by some facilities that allow physicians to state in advance that transcribed reports should automatically be considered approved and signed (or authenticated) when the physician fails to make corrections within a preestablished time frame (e.g., "Consider it signed if I do not make changes within 7 days."). Another version of this practice is when physicians authorize the HIM department to send weekly lists of unsigned documents. The physician then signs the list in lieu of signing each individual report. Neither practice ensures that the physician has reviewed and approved each report individually. One of the patients at your physician group practice has asked for an electronic copy of her medical record. Your electronic computer system will not allow you to accommodate this request. Chances are, you are NOT in compliance with the HIPAA Privacy Rule. Conditions of Coverage rules. meaningful use requirements. Joint Commission standards. - ✔✔-meaningful use requirements Certified EHRs must have the functionality to allow the creation of an electronic copy of the patient's health record. In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the commission's national patient safety goals, the focus has shifted to the use of prohibited or "dangerous" abbreviations. prohibited use of any abbreviations. use of abbreviations in the final diagnosis. flagrant use of specialty-specific abbreviations. - ✔✔-use of prohibited or "dangerous" abbreviations. As part of its National Patient Safety Goals initiative, the Joint Commission required hospitals to prohibit abbreviations that have caused confusion or problems in their handwritten form, such as "U" for unit, which can be mistaken for "O". Spelling out the word "unit" is preferred. One of the Joint Commission National Patient Safety Goals (NSPGs) requires that health care organizations eliminate wrong-site, wrong-patient, and wrong-procedure surgery. In order to accomplish this, which of the following would NOT be considered part of a preoperative verification process? Review the medical records and/or imaging studies. Follow the daily surgical patient listing for the surgery suite if the patient has been sedated. Confirm the patient's true identity. Mark the surgical site. - ✔✔-Follow the daily surgical patient listing for the surgery suite if the patient has been sedated "Confirm the patient's true identity," "mark the surgical site," and "review the medical records and/or imaging studies"—these are usually in the protocol to prevent wrong site, wrong patient, or wrong surgery. The correct answer is following the daily surgical patient listing—that choice would NOT be an appropriate step in making sure you have the correct identity of the patient, the correct site, or the correct surgery. A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the nurses' notes. integrated progress notes. incident report. doctors' progress notes. - ✔✔-incident report. Factual summaries investigating unexpected facility events should not be treated as part of the patient's health information and therefore would not be recorded in the health record. A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the history and physical is true in this situation? Completion and charting of the H&P indicates compliance with Joint Commission standards for nonsurgical patients. noncompliance with Joint Commission standards. compliance with Joint Commission standards. compliance with Medicare regulations. - ✔✔-noncompliance with Joint Commission standards. Joint Commission specifies that H&Ps must be completed within 24 hours or prior to surgery. As part of a quality improvement study, you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records. The best place in the record to locate this information is the postpartum record. prenatal record. labor and delivery record. discharge summary. - ✔✔-prenatal record. The antepartum or prenatal record should include a comprehensive history and physical exam on each OB patient visit with particular attention to menstrual and reproductive history. Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS but NOT in the UHDDS would be personal identification. procedures and dates. principal diagnosis. cognitive patterns. - ✔✔-cognitive patterns. Principal diagnosis, procedures and data, and personal identification represent items collected on Medicare inpatients according to UHDDS requirements. Only cognitive patterns represent a data item collected more typically in long-term care settings and required in the Minimum Data Set for Long Term Care. The foundation for communicating all patient care goals in long-term care settings is the interdisciplinary plan of care. Uniform Hospital Discharge Data Set. cognitive assessment. legal assessment. - ✔✔-interdisciplinary plan of care Unlike the acute care hospital, where most health care practitioners document separately, the patient care plan is the foundation around which patient care is organized in long-term care facilities because it contains the unique perspective of each discipline involved. The federally mandated resident assessment instrument used in long-term care facilities consists of three basic components, including the new care area assessment, utilization guidelines, and the UHDDS. MDS. OASIS. DEEDS. - ✔✔-MDS The Minimum Data Set (MDS) is a basic component of the long-term care RAI. UHDDS is used primarily in acute care. OASIS is used in home health, and DEEDS is used in emergency departments. For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the interdisciplinary patient care plan. problem list. discharge summary. transfer record. - ✔✔-problem list Patient care plans, pharmacy consultations, and transfer summaries are likely to be found on the records of long-term care patients. You have been asked by a peer review committee to print a list of the medical record numbers of all patients who had CABGs performed in the past year at your acute care hospital. Which secondary data source could be used to quickly gather this information? disease index master patient index operation index physician index - ✔✔-operation index The master patient index—the disease index is a listing in diagnostic code number order. Physician index—The physician index is a listing of cases in order by physician name or number. Disease index— The MPI cross-references the patient name and medical record number. Therefore, operation index is the correct choice. As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman that a new H&P is required for every inpatient admission. you apologize for not noticing the H&P she provided. the H&P copy is acceptable as long as she documents any interval changes. Joint Commission standards do not allow copies of any kind in the original record. - ✔✔-the H&P copy is acceptable as long as she documents any interval changes. Joint Commission and COP allow a legible copy of a recent H&P done in a doctor's office in lieu of an admission H&P as long as interval changes are documented in the record upon admission. In addition, when the patient is readmitted within 30 days for the same or a related problem, an interval history and physical exam may be completed if the original H&P is readily available. As a working HIM professional, you are investigating the workforce development projections of electronic health record specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need to regularly access the website of this governmental agency. ONC CDC OSHA CMS - ✔✔-ONC The Office of the National Coordinator (ONC) for Health Information Technology is the federal agency charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information. Engaging patients and their families in health care decisions is one of the core objectives for the Joint Commission's National Patient Safety goals. HIPAA 5010 regulations. establishing flexible clinical pathways. achieving meaningful use of EHRs. - ✔✔-achieving meaningful use of EHRs. There are several core objectives for achieving meaningful use. Engaging patients and their families is one of these core objectives. Ultimate responsibility for the quality and completion of entries in patient health records belongs to the chief of staff. HIM director. risk manager. attending physician. - ✔✔-attending physician. Although the nursing staff, hospital administration, and the health information management professional play a role in ensuring an accurate and complete record, the major responsibility lies with the attending physician. The minimum length of time for retaining original medical records is primarily governed by medical staff. Joint Commission. state law. readmission rates. - ✔✔-state law The statute of limitations for each state is information that is cru [Show More]

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