WGU C808 Classification Systems Objective Assessment Study Guide - Exam Ready A+ Scored

WGU C808 Classification Systems Objective Assessment Study Guide - Exam Ready A+ Scored Copy/Paste Functionality - answer - Should be prevented by creating organizational policies. Problem with this occurrence accuracy of the health record, certify the record as a legal document when the original source is difficult to establish, and disclosure of information to the wrong patient. Record Retention Policies - answer - Allows the HIM professional to know what data needs to be maintained. Patient Identity Management - answer - Is a huge issue in today's connected environment. Ensuring that the right patient is connected with the right information relies on accurate patient identity management. Master Patient Index (MPI) (Note: The care provider is responsible for ensuring that EHR entries are High Quality.) EHR Entry Policies - answer - 1. Entries must be authenticated and dated ( Name + Status) 2. All paper entries should be in ink 3. No erasures or deletions should be made 4. If correcting a paper record, one like should be drawn neatly thought the error, leaving the incorrect material legible. The error should be initialed and dated. In an EHR the error should be noted + hidden. ( not deleted) 5. Original reports should be always kept. Scans + lab results may be replaced. 6. No blank spaces in process and nurse notes. If blanks mark with an X. 7. All blanks should be completed. Especially, on consent forms. 8. When health records are filed incomplete, a statement should be attached to indicate the case, signed by chief of staff or chair of the health record committee. 9. Chart folder labeling, dotting, or other methods of identifying at a glance a particular type of patient, such as one with a drug or alcohol diagnosis or HIV- Positive status, should be discouraged to prevent inadvertent breaches of confidentiality. Advance Directive - answer - A written document, such as a living will, that states the patient's preferences for care in the event that the patients condition prevents him or her from making care decisions. Durable Power of Attorney - answer - Is a document that names someone to make decisions from the patient if the patient is unable to make these decisions. The person is often called a proxy. Goes into effect when the physician determines the patient is no longer able to communicate about health care decisions. Time Frame for Health and Physical - answer - 24 hours following admission and require that the history and physical be completed by the practitioner who is admitting the patient. CMS Conditions of participation require that the h&P be completed no more the 30 days before or 24 hours after admission and the report must be placed in the record with 24 hours after admission. Chief Complaint - answer - Nature and duration of the symptoms that caused the patient to seek medical attention as stated in his or her own words. Present Illness - answer - Detailed chronological description of the development of the patients illness, from the appearance of the first symptom to present. Past Medical History - answer - Summary of childhood and adult illnesses and conditions, such as infectious diseases, pregnancies, allergies and drug sensitivities, accidents, operations, hospitalizations, and current medications. Social and Personal History - answer - Marital status; dietary, sleep and exercise patterns; use of coffee, tobacco, alcohol, and other drugs; occupation; home environment; daily routine; and so on. Family Medical History - answer - Diseases among relatives in which heredity or contact might play a role, such as allergies, cancer, and infectious, psychiatric, metabolic, endocrine, cardiovascular, and renal diseases; health status or cause of and age at death for immediate relatives. Review of Systems - answer - Systematic inventory designed to uncover current or past subjective symptoms that includes the following types of data: * General: Usual weight, recent weight changes, fever, weakness,