RHIA domain 1 Questions And Answers Rated 100% Correct!!

Which of the following is used by a long-term care facility to gather information about specific health status factors and includes information about specific risk factors in the resident's care? - ️️minimum data set Mr. Smith was admitted to University Hospital by Dr. Collins. Mr. Smith's hospital bill will be paid by Blue Cross Insurance. Upon discharge from the hospital, who owns the health record of Mr. Smith? - ️️University Hospital structured information used to increase the effective use of data - ️️metadata data element name, data type, and field length are examples of what kind of data - ️️metadata all documentation entered in the medical record relating to the patient's diagnosis and treatment are considered this type of data - ️️clinical data . A 65-year-old white male was admitted to 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 n ICD-10-PCS, what value is used if there is a character that does not apply to a given code? - ️️Z required elements in an emergency care record - ️️time and means of the patient's arrival, treatment rendered, instructions at discharge In a long-term care setting, these are problem-oriented frameworks for additional patient assessment based on problem identification items (triggered conditions): - ️️Resident Assessment Protocols (RAPs) a data element name is considered which of the following: a. master data b. metadata c. structured data d. unstructured data - ️️bWhat type of information makes it easy for hospitals to compare and combine the contents of multiple patient health records? - ️️uniform data sets component of the resident assessment instrument (RAI) used to collect information about the resident's risk factors and plans ongoing care and treatment of the resident at the LTC facility - ️️minimum data set Documenting the full depth and breadth of data use in a healthcare entity requires: - ️️identifying the needs of the data consumers The primary responsibility of a coder is to: - ️️ensure accuracy of coded data Notes written by physicians and other practitioners as well as dictated and transcribed reports are examples of: - ️️unstructured data Data that have been grouped into meaningful categories according to a classification system are referred to as this type of data - ️️coded Which part of the problem-oriented health record is used by many facilities that have adopted the whole problem-oriented format? - ️️The SOAP form of progress notes Borrowing record entries from another source as well as representing or displaying past documentation as current are examples of a potential breach of: - ️️authorship integrity According to Joint Commission Accreditation Standards, which document must be placed in the patient's record before a surgical procedure may be performed? - ️️history and physical Data that are collected on large populations of individuals and stored in databases are referred to as: - ️️aggregate data Decision making and authority over data-related matters is known as - ️️data governance contains a summary of the care provided in the facility from which the patient is being transferred as well as the reason for transfer - ️️transfer record Mildred Smith was admitted to a nursing facility with the following information: "Patient is being admitted for Organic Brain Syndrome." Underneath the diagnosis her medical information was listed along with a summary of the care already provided. This information is documented on the: - ️️transfer recordthe process by which a person or entity who authored an EHR entry or document seeks to validate that they are responsible for the data contained within it is called: - ️️authentication Patients to consulting physicians is what type of relationship - ️️many to many When defining the legal health record in a healthcare entity, it is best practice to establish a policy statement of the legal health record as well as a: - ️️health record matrix identifies and tracks the physical location of each paper document and the source of each electronic document that constitutes the LHR - ️️health record matrix Anywhere Hospital has mandated that the Social Security number will be displayed in the XXX-XX-XXXX format for their patients. This is an example of the use of a: - ️️mask this is used in a data dictionary to control that format used to display data - ️️mask