Samuelmgichuki96

The patient is required to do what before the start of any invasive procedure? - informed consent Occurs when a patient is in need of immediate medical services but is unconscous or is physically unable to consent to treatment. In this case, services are rendered with the assumption that the patient would consent if able - implied consent What are vital signs? - temperature, pulse, blood pressure, respirations The measurement of basic body functions to monitor critical information regarding...

clinical information - data that pertains to patients dxs, treatment and patient progress administrative information - data that pertains to patients demographics, insurance, consents, and authorizations Data Quality - The reliability and effectiveness of data for its intended uses in operations, decision making, and planning Accuracy - data is free of errors and reflects the true data values Accessibility - ability to provide access to health information to those who needed it when need...

The ICD-10-CM diagnostic codes are used to report diagnoses for: - Inpatient hospital services only The phrase "fracture of the left ulnar" would be located in the Alphabetic Index by referencing the main term: - Fracture The phrase "acquired deformity of the right wrist" would be located in the Alphabetic Index by referencing the main term: - Deformity The notation "SEE:" is used: - In the Alphabetic Index; is mandatory and instructs the coder to cross- reference the term listed Th...

HIT 141 Midterm Complete Solutions 2024/2025 | Already Passed In the following example, "Rales R09.89" is a? Rake teeth, tooth M26.39 Rales R09.89 Ramifying renal pelvis Q63.8 - Main term In the following example "--antibody titer R76.0" is a?Raised - see also Elevated -- antibody titer R76.0 - Carryover line Railroad neurosis F48.8 Is an example of a? - Main term In the following example "--Hunt's disease) B02.21" is a?Ramsay-Hunt disease or syndrome- (see also --Hunt's disease...

Which of the following clinical data elements is NOT usually documented in the acute-care health record? A. Clinical observations B. Medical history C. Immunization records D. Discharge summary - C. Immunization records Results of a urinalysis and all blood tests performed would be found in what part of a healthcare record? A. Autopsy report B. Operative report C. Pathology report D. Laboratory report - D. Laboratory report What is the function of a consultation report? A. Provides ...

HIT 141 HEALTH INFORMATION PROCESSES Complete Solutions 2024/2025 | Already Passed Which of the following clinical data elements is NOT usually documented in the acute-care health record? - immunization records Which of the following is NOT true about the surgical procedure documentation? - It includes laboratory results An RAI/MDS and care plan are found in records of patients in _____. - long- term care Which of the following documents is usually found in a behavioral healthcare recor...

HIT 141 Q&A 5 Complete Solutions 2024/2025 | Already Passed The acute care record - clinical data and administrative data Clinical Data - include a primary diagnosis that identifies the condition or illness for which the patient needs medical care, vital signs, laboratory and test results, progress notes, and more. Administrative data - demographic, financial information, consents, authorizations, acknowledgments, and advance directives. The face sheet - identification, admission diagnosis...

HIT 141 Q & A 4 Complete Solutions 2024/2025 | Already Passed identify the type of health record controlled by patients - personal health record explain how amendments to the EHR are handled - the amendment must have a separate signature, date, and time version control of documents in the EHR requires - policy and procedures to control which version is displayed the decision was made to not allow copying and pasting - coping outdated information when 1 key in the computer displays it as ...

Which of the following should be included in a covered entity's notice of privacy practices? - Description with one example of disclosures made for treatment purposes -HIPAA mandates what must be included in the notice of privacy practices. This includes one example of disclosures for treatment purposes. Which of the following is true of the Health Insurance Portability and Accountability Act (HIPAA)? - Provides a federal floor for healthcare privacy- HIPAA is a federal floor for privacy....

HIT 141 Q&A 3 Complete Solutions 2024/2025 | Already Passed Which of the following clinical data elements is not usually documented in the acute care health record - Records of immunizations Results of a urinalysis, and all blood test performed would be found in what part of a health care record - Laboratory report What is the function of a consultation report? - Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's ...