HIM 317 Final Exam Review | latest 2023/24 | with complete solution

HIM 317 Final Exam Review | latest 2023/24 | with complete solution Both the Joint Commission and CMS expect this documentation to be placed in the hospital patient's record before a surgical procedure is performed. history and physical examination Hospitals accredited by the Joint Commission or the AOA are also considered in compliance with Medicare Conditions of Participation, an official designation called______ status. deemed A health record is arranged in chronological order with documentation from various sources intermingled. This is an example of the ______format. integrated What does "P" in "SOAP" stand for? Plan of treatment Data exchange, or message format, standards support EHR interoperability. The structure or format of data elements in a message is referred to as _______. syntax You're asked to develop a new electronic health record screen view. Your first priority in preparing a draft should be: The needs of the users Which organization has created standards for EHR system functions? HL7 Also known as a clinical resume, this document provides a concise account of the patient's illness, course of treatment, response and condition on exit from the hospital. The physician principally responsible for the patient's care composes and signs it. Discharge summary Before a hospital is permitted to provide medical services in a particular state, the organization must first go through what process? Licensure A patient medical record is an example of a ____. Primary data source What is the term used for the official business record created by or for the health care organization? Legal health record Before a physician will be permitted to provide patient services in a specific facility, or make entries in a record, he/she must first go through which of the following processes? Credentialing and privileging What health record format is in use when documents are grouped together according to their point of origin? Source-oriented Which health record format is arranged n chronological order with documentation from various sources? Integrated What is the MOST important component of the health records? Clinical documentation What is the outcome of analyzing data for a specific purpose? Information