Questions, Answers &
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, 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)
Recommendation for improvement from TJC # of delinquent records is >50% AND Delinquent records missing H&P >2% of the
Average monthly DCs
Integrated vs Separated Progress notes Integrated - all providers from every discipline record progress notes sequentially
on the same form
vs
Separated - every discipline has its own designated form to record their Progress
notes
LTC pt care plans rely on documentation found in 1) Interdisciplinary pt care plan
2) DC summary
3) Transfer records
Ambulatory care providers rely on documentation found Problem list
in
Core measures quality indicators for compliance with MI - pt is DC'd on ASA, beta blockers or other heart Rxs
HCQIP (Medicare Health Care Quality Improvement Stroke - pt is DC'd on an anti-thrombotic
Program) Pneumonia - pt had blood culture before 1st Abx started
Regional health information organizations Support health information exchange within a geographic region
One essential item on Physical exam General appearance as assessed by MD (Chief complaint, ROS & Family Hx -
medical Hx provided by the pt)