Abstracting Study guides, Class notes & Summaries

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 (Ans- d. UHDDS (Uniform Hospital Discharge Data Set) The Uniform Hospital Discharge Data Set (UHDDS) data cha...

abstracting - ️️Reviewing medical record documentation to discover clinical concepts that support assigning codes to the highest level of specificity. clinical documentation - ️️Information recorded in the medical record pertaining to the health status of a patient as determined by a health care provider. CPT - ️️Current Procedural Terminology. Codes for services and procedures. electronic health record (EHR) - ️️A digital version of a patient's chart that includes info...

HISM (D033): CHAPTER 6 2024 WITH 100% ACCURATE SOLUTIONS Healthcare quality indicator system - correct answer An abstracting system that records information about the patient, the care provided to the patient, and the healthcare practitioner(s) involved in the care delivered Automated codebook encoder - correct answer An encoder that lists diagnoses and procedures in alphabetic order much like the alphabetic index Birth certificate information system - correct answer A state-approved sy...

RHIT Domain 3 Question and answers rated A+ 2023/2024Community Hospital had 250 patients in the hospital at midnight on May 1. The hospital admitted 30 patients on May 2. The hospital discharged 40 patients, including deaths, on May 2. Two patients were both admitted and discharged on May 2. What was the total number of inpatient service days for May 2? a. 240 b. 242 c. 280 d. 320 - correct answer b A unit of measure that reflects the services received by one inpatient during a 24-hour pe...

Classification of the extent of disease is known as: Grading Coding Abstracting Staging - ️️Staging Examples of confidential information under HIPAA include the following except: Patient account passwords Patient SSNs Patient home address De-identified clinical information - ️️De-identified clinical information State collection of follow-up cancer data can be collected.... With patient consent With permission of the patient's primary physician With permission of the pa...

CCA Exam Preparation Updated Questions and Answers ;All domain modules with complete solutions During an audit of health records, the HIM director finds that transcribed reports are being changed by the author up to a week after initial transcription. The director is concerned that changes occurring this long after transcription jeopardize the legal principle that documentation must occur near the time of the event. To remedy this situation, the HIM director should recommend which of the foll...

A physician group is adopting a new electronic health record (EHR). Some members of the group prefer to dictate, and others prefer direct data entry. Which data capture method should the EHR coordinator recommend to meet the needs of all physicians? - Voice data entry - Structured data entry - Template-based entry - Unstructured data entry Template-based entry A hospital's health information management (HIM) department receives numerous pages of loose documentation on a daily basis to ...

A survey extension would be granted for correct answer: natural disasters (e.g., flood, hurricane) or other disasters (e.g. fire). Extensions are not granted for issues related to registry operations such as delayed abstracting, deficiencies in standards, software conversion, or the resignation of staff. SAR is the acronym for correct answer: Survey application record What requirement determines the percentage of patients enrolled in clinical trials each calendar year? correct answer: T...

A health record technician has been asked to review the discharge patient abstracting module of a proposed new 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? (Ans- UHDDS Standardizing medical terminology to avoid differences in naming various health conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and...

A physician group is adopting a new electronic health record (EHR). Some members of the group prefer to dictate, and others prefer direct data entry. Which data capture method should the EHR coordinator recommend to meet the needs of all physicians? - Voice data entry - Structured data entry - Template-based entry - Unstructured data entry - correct answer Template-based entry A hospital's health information management (HIM) department receives numerous pages of loose docume...