RHIT EXAM Health Data Content and Standards Final Quiz 1.1 ANSWERS

In preparation for an EHR, you are conducting a total facility inventory of all forms currently use. 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 on tissue excised during surgery. The document type you are most likely to give to this is - PATHOLOGY REPORT * only the pathology report will contain a microscopic description. Patient data collection requirements vary according to healthcare settings. A data element you would expect to be collected in the MDS, not in the UHHDS would be: - COGNITIVE PATTERNS *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:* - *USE OF PROHIBITED OR "DANGEROUS ABBREVIATION* Engaging patient and their families in health care decisions is one of the core objectives for: - ACHIEVING MEANINGFUL USE OF EHR 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 : - *INCIDENT REPORT* *For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the:* - *PROBLEM LIST* Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that: - EVIDENCE CANNOT BE PROVIDED THAT THE PHYSICIAN ACTUALLY REVIEWED AND APPROVED EACH REPORT. 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: - PRENATAL RECORD *The antepartum record should include a comprehensive history and physical exam on each OB patient visit, with particular attention to menstrual and reproductive history.