CIC Exam Prep Chapter 4 Documentation

Who can make entries in the medical record? - ANSWER-Physicians, nurse practitioners, nurses, and other members of the healthcare team. Uniform Hospital Discharge Data Set The data elements required by UHDDS include: - ANSWER-Personal Patient identifier date of birth Sex race ethnicity residence hospital identification admission date type of admission discharge date the attending physician's identification Operating physician identification PRINCIPAL diagnosis OTHER diagnoses external cause of injury codes birth weight of neonates Procedures and dates disposition of patient expected payment source total charges Regardless of setting, Or regulatory or accreditation requirements, the healthcare record must support the ________ and subsequent treatment of the patient. - ANSWER-condition (diagnosis) The documentation found in the healthcare record justifies the _______ and _______ the patient receives, and therefore must be adequate. - ANSWER-treatment and services MDS: The minimum data set is required by CMS for ______ ________. - ANSWER-nursing facilities The __________ is a tool that can be used to implement standardized assessments and management of care and is a mandated process for all residents in a Medicare or Medicaid Certified nursing facility. - ANSWER-MDS The process to identify trends and patterns in a database. It can be useful in many ways, including detecting fraud and abuse and identifying effective treatments and efficiencies. - ANSWER-Data mining