Health Computing - RHIT Exam Prep (complete 2022 solution guide)

Health Computing - RHIT Exam Prep (complete 2022 solution guide) Example of Point-of-Service care & documentation 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? 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? No guarantee that MD actually reviewed the MR & did sign it electronically. Some facilities do use auto athentication In what setting Interdisciplinary plan of care is used? LTC TJC compliance rate for Delinquent records is Under 50% Who is responsible for accurateness & completeness of pts MRs? MDs (not HIM director, RNs or other administrative positions) Dictated Operative report is due Immediately after surgery. If transcription service is down, the surgeon has to write a detailed OP note One of Utilization Review functions Compare severity of illness & Intensity of service warrant acute care level One of Clinical Care Eval processes Quality of follow-up care Tumor registry cases accession numbers Each case in Tumor registry is assigned a unique accession number. Ex: 10-001 (10- year the case was entered in a database, 001 - case #1) What is accession register? Permanent log of all cases entered in a database (used in Tumor registry) What is R-ADT system? Registration-Admission, DC & Transfer system. Best to use for tracking pts who have been transferred to a specialty unit Difference between ROS & H&P 1) Review of Systems - record of subjective Sx that a pt may have forgotten to mention 2) H&P - record of Objective Sx MD is observing & other info (social Hx, Hx of present illness) Recommendation for improvement from TJC # of delinquent records is 50% AND Delinquent records missing H&P 2% of the Average monthly DCs Integrated vs Separated Progress notes Integrated - all providers from every discipline record progress notes sequentially on the same form vs Separated - every discipline has its own designated form to record their Progress notes LTC pt care plans rely on documentation found in 1) Interdisciplinary pt care plan 2) DC summary 3) Transfer records Ambulatory care providers rely on documentation found in Problem list Core measures quality indicators for compliance with HCQIP (Medicare Health Care Quality Improvement Program) MI - pt is DC'd on ASA, beta blockers or other heart Rxs Stroke - pt is DC'd on an anti-thrombotic Pneumonia - pt had blood culture before 1st Abx started Regional health information organizations Support health information exchange within a geographic region One essential item on Physical exam General appearance as assessed by MD (Chief complaint, ROS & Family Hx - medical Hx provided by the pt) Elements of which data set do I collect if I'm a trauma registrar? DEEDs (Data Elements for EDs) - recommended data set for hospital-based EDs Data set for Acute Care hospitals UHDDS (Uniform Hospital Data Set) - required data set for Acute Care hospitals Data set for LTC MDS (Minimum Data Set) - required data set for LTCs ORYX An initiative of TJC that implements 5 core measures to improve safety and quality of health care. 5 core measures of ORYX CHF. AMI. Pneumonia (CAP). Each has requirements, e.g. ASA at arrival & DC, beta-blockers, blood culture, smoking cessation advice, etc. ORYX has more core measure sets. A hospital chooses the set according to the type of pts it treats (can be one core & rest non-core) Quantitative vs Qualitative analysis of MRs Quantitative - check presence or absence of necessary sigs, reports vs Qualitative - check documentation consistency, e.g. compare pt's Rx profile to MAR. Quality of documentation NOT clinical care