RHIA Exam Review | Questions with 100% Correct Answers | Verified | Latest Update 2024

In preparation for an EHR, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is: A. recovery room record B. pathology report C. operative report D. discharge summary - B. pathology report Although a gross description of tissue removed may be mentioned on the operative note or discharge summary, only the pathology report will contain a microscopic description. Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS, but NOT in the UHDDS would be: A. personal identification B. cognitive patterns C. procedures and dates D. principal diagnosis - B. cognitive patterns The other answer choices represent items collected on Medicare inpatients according to UHDDS requirements. Only "cognitive patterns" represents a data item collected more typically in long-term care settings and required in the MDS In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to the A. prohibited use of any abbreviations B. flagrant use of specialty-specific abbreviations C. use of prohibited or "dangerous" abbreviations