Intro to HIM Final | with complete solution | updated

Intro to HIM Final | with complete solution | updated What is the national association for HIM professionals? - AHIMA - American Health Information Management Association. What is the role of the HIM professional within the healthcare organization? - 1. Conducting a data content standards requirements analysis 2. Developing a local data dictionary to support enterprise-wide interoperability 3. Advancing the development of data content standards 4. Contributing to domain knowledge by participating in relevant professional association work 5. Contributing to the development and harmonization of industry and professional standards What are the two credentials available to HIM professionals? - Registered Health Information Technician (RHIT) Registered Health Information Administrator (RHIA) What is the purpose of the patient's health record? - The health record is the principal repository (storage place) for data and information about the healthcare services provided to an individual patient. It documents the who, what, when, where, why, and how of patient care. The health record also records the health status of the patient. Who uses the patient's health record? - • patient care providers • Managed care organizations • integrated healthcare delivery systems • regulatory and accreditation organizations • licensing bodies • educational organizations • third-party payers • research facilities Is the health record a primary or secondary source of information - The health record is a primary source of information. Can you provide examples of secondary sources of information? - • MPI - Master Patient Index • Disease and Operation Index • Physician Index • Registries What are the three formats for the paper-based health record? Describe these 3 formats. - • Source Oriented - documents are grouped together according to their point of origin. • Problem Oriented - an itemized list of the patient's past and present social, psychological, and medical problems. Each problem is identified by a unique number. • Integrated - arranged so that the documentation from various sources is intermingled and follows strict chronological order. What determines the patient's level of care? - Utilization management - a set of processes used to determine the appropriateness of medical services. Patient Diagnosis site of care, the length of stay and other clinical factors. What is the role of the Medical Staff Committee? - Put in place to oversee ongoing and cross-functional issues What is the role of the hospitalist within healthcare? - The hospitalist is a physician dedicated to hospital-based care services. Physician employed by teaching hospitals to play the role that admitting physicians fulfill in hospitals that are not affiliated with medical training programs Can you name some regulatory and accrediting agencies that govern the healthcare record? - CMS - Centers for Medicare and Medicaid Services The Joint Commission What is the role of Risk Management? - • Risk identification and analysis • Loss prevention and reduction • Claims management What is a critical care access hospital? - A critical care access hospital is a rural community hospital that receives cost-based reimbursement. Specialty hospital - A specialty hospital is a hospital that provides a limited range of services and in which two-thirds of Medicare patients receive care for just two Diagnosis-Related Groups. Rehabilitation hospital - A Rehabilitation hospital is a hospital that provides rehabilitation care to patients with various neurological, musculoskeletal, orthopedic and other medical conditions following stabilization of their acute medical issues. Adult Daycare Center - Adult day services is a professional care setting in which older adults, adults living with dementia, or adults living with disabilities receive individualized therapeutic, social, and health services for some part of the day. What services do a skilled nursing facility provide? - They offer long- and short-term care for individuals who need rehabilitation services or who suffer from serious or persistent health issues, such as Alzheimer's disease, that are too complicated to be tended to at home or at an assisted living facility. palliative care - A type of medical care designed to relieve the patient's pain and suffering without attempting to cure the underlying disease two types of data contained within the patient's health record - Clinical - documents the patient's medical condition. Administrative - includes demographic and financial information. two external agencies that govern the patient's health record - Accreditation Association for Ambulatory Healthcare (AAAHC) Centers for Medicare and Medicaid Services (CMS) purpose of the Discharge Summary - An account of the patient's illness, the course of treatment, response to treatment and condition at the time of patient discharge. What are the timeliness requirements of the Discharge Summary? - The JC requires that a discharge summary is completed within 30 days of discharge. What is the purpose of the History and Physical - The H & P records a patient's story and serves as a legal document concerning patient care. What are the timeliness requirements of the History and Physical? - The H & P must be completed and documented within 24 hours following patient admission but prior to surgery or a procedure requiring anesthesia. What is the purpose of the physician's order? - To communicate the medical care that the patient is to receive while in the hospital as well as document tests, meds, and treatments that were ordered What is the frequency required of progress notes? - One progress note for each patient encounter. What is a pathology report? When is it required? - A document that describes the results of a microscopic and macroscopic evaluation of a specimen removed. One is required whenever tissue is removed for evaluation What is an autopsy report? Who signs the consent for an autopsy report? - A descripti