RHIA Domain 1Revised Questions and Answers / Sure A+

________ used to collect information about the resident's risk factors and to plan the ongoing care and treatment of the resident in the long term care facility. - minimum data set A 65 year old white male was admitted tot the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured appendix was discovered. The chief complaint was: - abdominal pain A local skilled nursing facility has been working to improve the quality of care it provides to residents..... Which of the following should the HIM professionla use to inform management on how the facility compares to others in the area? - comparative performance data a medical group practice has contracted with an HIM professional to help define the practice's legal health record. Which of the following should the HIM professional perform first to identify the components of the legal health record? - develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records A method of documenting nurses' progress notes by recording only abnormal or unusual findings or deviations from the prescribed plan of care is called - charting by exception according to joint commission accreditation standards, which document must be placed in the patient's record before a surgical procedure may be performed - report of history and physical examination