Answers Correct
AHIMA developed a data quality management model based on four domains. What four
domains? - ANSWERSData application
Data analysis
Data warehousing
Data collection
To understand doctor's notes better, Certified Coding Specialists, should:
Ask nurses to interpret it for them.
Ask management to interpret it for them.
Take medical terminology courses.
Guess what their notes mean. - ANSWERSTake medical terminology courses.
To understand doctor's notes better, Certified Coding Specialists should take medical
terminology courses. They will use this terminology to code medical charts, notes, and
medical tests.
According to the patient's file, a diagnostic statement 5 years ago completely contradicts
a recent diagnosis. This means that *this record* is NOT in line with what high-quality
clinical documentation principle?
Consistent.
Clear.
Timely.
None of these - ANSWERSConsistent-This record is not consistent.
There are seen criteria for high-quality clinical documentation.
These are:
*Legible* - "Clear enough to be read and easily deciphered."
*Reliable* - "Trustworthy, safe, yielding the same result when repeated."
*Precise* - "Accurate, exact, strictly defined."
*Complete* - "Having the maximum content, thorough." *Consistent*- "Not
contradictory."
*Clear* - "Unambiguous, intelligible, not vague."
*Timely* - "At the right time."
Medical records are organized and sequenced based on all of the following except:
-Where the medical practice is located.
-The type of medical procedure.
-Doctor preference.
-Frequency of access to records. - ANSWERSWhere the medical practice is located.
Organized medical records are based on:
*Type of medical procedure,