Health Computing - RHIT Exam Prep (complete 2022 solution guide)

Health Computing - RHIT Exam Prep (complete 2022 solution guide) 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) 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 in Problem list Core measures quality indicators for compliance with HCQIP (Medicare Health Care Quality Improvement Program) MI - pt is DC'd on ASA, beta blockers or other heart Rxs Stroke - pt is DC'd on an anti-thrombotic 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) Elements of which data set do I collect if I'm a trauma registrar? DEEDs (Data Elements for EDs) - recommended data set for hospital-based EDs Data set for Acute Care hospitals UHDDS (Uniform Hospital Data Set) - required data set for Acute Care hospitals Data set for LTC MDS (Minimum Data Set) - required data set for LTCs ORYX An initiative of TJC that implements 5 core measures to improve safety and quality of health care. 5 core measures of ORYX CHF. AMI. Pneumonia (CAP). Each has requirements, e.g. ASA at arrival & DC, beta-blockers, blood culture, smoking cessation advice, etc. ORYX has more core measure sets. A hospital chooses the set according to the type of pts it treats (can be one core & rest non-core) Quantitative vs Qualitative analysis of MRs Quantitative - check presence or absence of necessary sigs, reports vs Qualitative - check documentation consistency, e.g. compare pt's Rx profile to MAR. Quality of documentation NOT clinical care Index with Unique Identifier codes Physician index - not real MDs name, but codes. To protect MDs identity POMR Problem Oriented MR. Helps index documentation throughout MR H&P time standard to meet TJC & CoP requirements 24 hrs after admission or prior to surgery DC summary records Significant findings during hospitalization Time frame and copies of recent H&P per TJC Copies of recent H&P done in MD's office is allowed in lieu of admission H&P as long as the interval note (interval changes) are present upon admission When can Interval note replace H&P upon admission? 1) If pt is re-admitted within 30 days for the same problem & copy of recent H&P is available; 2) If copy of recent H&P done in MD's office is available upon admission Indices in hospital 1) MPI - cross-reference of pt's name & MR number; 2) Disease index - a listing in diagnostic code number order (I can use it to get stats on # of a Dz cases); 3) Physician index - a listing of cases in order by MD's name or number; 4) Operation index - a listing of operations performed Most serious delinquencies 1) H&P; 2) Operative report; Formal release of pt from hospital is DC order. If DC order is missing - pt is assumed to leave AMA Who can accept VOs? Persons designated by hospital's P&Ps and State & Federal laws When is problem list required? On 3rd visit RHIO Regional Health Information Organization - network allowing providers to access pts MRs Info on MR supplied by a pt Health Hx, CC & ROS - all subjective Data comprehensiveness Presence of all required data elements CARF Commission on Accreditation of Rehab Facilities Pt certification period in Home Health 60 days. Certification period is a summary on each pt Data reliability Data are consistent no matter how many times the same data are collected & entered into a system Final Progress Note can substitute for a DC summary 1) Pts in hospital for 40 hrs C minor problem; 2) Normal NBs; 3) Uncomplicated OB deliveries Authors in MR should be ID's by Biometrics, e.g. Joe Smith, RN. Other types (sig, initials) must be uniquely identifiable RAI components in LTC facilities