RHIA & RHIT

Correct Answer: A Information about a patient is collected during the course of receiving healthcare services. This includes demographic data used to identify an individual (Gordon and Gordon 2016a, 422). - Answer "What are the patient data such as name, age, and address called? a. Demographic data b. Secondary data c. Aggregate data d. Identification data Correct Answer: A Patient care delivery is a primary purpose of the health record. Other primary purposes are patient care manage...

ONC - Answer The Office of the National Coordinator for Health Information Technology is the federal agency charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information. The function of a(an) _______ is limited to data retrieval. - Answer "clinical data repository " retrospective quantitative analysis of a health record - Answer retrospective study looks backwards and examines...

One important element of data quality is security in preventing unauthorized access, corruption, misuse, and loss of data. Technical and procedural methods will be used with the CPR to control and manage confidential information. An example of a of protecting data thru a procedural method is: Confidentiality statements signed by all staff Limiting access of certain screens based on the staff's need to know Auditing capability of system to track data access Computer back-up system - An...

DEEDS - Answer Data Elements for Emergency Department Systems (Used for Emergency Department) EMDS - Answer Electronic Document Management System HEDIS - Answer Health Plan Employer Data and Information Set (used for Managed Care and is designed to organize data for public release about the outcomes of care) MDS - Answer Minimum Data Set (Used in Long Term Care) NCDB - Answer National Cancer Database OASIS - Answer Outcome and Assessment Information Set (Used for home ...

(113) If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following? A) Length of the lesion as described in the pathology report B) Dimension of the specimen submitted as described in the pathology report C) Width times the length of the lesion as described in the operative report D) Diameter of the lesion as well as the margins excised as described in the operative report - Answer D)...

A health record technician has been asked to review the discharge patient abstracting module of a proposed new electronic health record (EHR). Which of the following data sets would the technician consult to ensure the system collects all federally required discharge data elements for Medicare and Medicaid inpatients in an acute-care hospital? a. CARF b. DEEDS c. UACDS d. UHDDS - Answer d. UHDDS (Uniform Hospital Discharge Data Set) The Uniform Hospital Discharge Data Set (UHDDS) dat...

Fee-for -service is a healthcare payment method in which A. Physicians payments is determined B. Skilled nursing facilities reimbursed is Determined C. Providers received payment for services rendered D. Claim denials are processed - Answer C. Providers received payment for services rendered One of the purposes of the hospital payment monitoring program is to A. Measure the outpatient payment error rate B. Reduce necessary hospital admissions rate C. Reduce the physician fee for serv...

Abuse - Answer A range of the following improper behaviors or billing practices including, but are not limited to: billing for non-covered services, misusing codes on a claim Access - Answer As amended by HITECH, the ability or means necessary to read, write, modify, or communicate data/information Access Control - Answer a computer software program designed to prevent unauthorized use of an information resource Accession number - Answer A unique identifier for the patient consi...

Example of Point-of-Service care & documentation - Answer RN using a terminal to record vital signs. There's a difference between computer application in health care and clinical application of computers What do I find in Medical Staff Rules & Regulations? - Answer Doc requirements for pts' records, time frame for completion of MRs, penalties for failure to comply C these requirements Auto authentication. Why doesn't TJC approve it? - Answer No guarantee that MD actually reviewed ...

Master or Enterprise patient index - Answer is critical to identifying patients and ensuring proper record linkage The health record consist of - Answer handwritten notes, transcribed reports, electronic data, digital images Continuity of care - Answer is improved by the sharing of patient information between providers Standards and regulations - Answer have a great impact on what is documented in the health record The American College of Surgeons (ACS) - Answer developed t...