(UHDDS) Uniform Hospital Discharge Data Set - Answers seeks to improve the standardization
and comparability of hospital discharge data and is used primarily in acute care facilities
quantitative record review - Answers aims is to determine whether a document is complete
authenticated, and timely
qualitative analysis - Answers may involve checking documentation consistency, such as
comparing a patient's pharmacy drug profile with the medication administration record.
utilization review - Answers completed by a health insurance company. The third-party payer is
seeking opportunity to review a request for a medical procedure or service. The goal of the
review is to confirm that the plan provides coverage for your medical treatment.
legal review - Answers review of legal facets of healthcare to include legal analysis on HIPAA
regulations, non-profit organization status, to home health and abuse. Legal analysis ensures
that the record entries would be acceptable in a court of law.
comprehensiveness - Answers refers specifically to the presence of all required data elements.
Accuracy - Answers denotes that data are correct values. is tied more closely to data input than
data output
Data Security - Answers aims to protect digital data from damaging forces, unauthorized uses,
and data breaches
(APGAR) Appearance, Pulse, Grimace, Activity, and Respiration - Answers This is the test used
to assess a baby's health at birth
The specific information regarding which employees have been given authority to transcribe
verbal orders in your facility should be located in your hospital's - Answers bylaws, rules, and
regulations
Cognitive assessment - Answers evaluate the cognitive capabilities of the patient. Cognition
involved the ability to thinking, memory, language, judgment, as well as the aptitude to learn new
things
(R-ADT) Registration, Admission, Discharge, Transfer Systems - Answers tracks when patients
are admitted to the hospital or outpatient services and opens an account.
Omnibus Budget Reconciliation Act (OBRA) - Answers mandates comprehensive functional
assessments of long-term care residents using the Minimum Data Set (MDS) for Long-Term
Care
Uniform Clinical Data Set (UCDS) - Answers focused on data collection and case finding system
developed by the Health Care Financing Administration. The aim is to assure, through the Peer