c810 introduction to health records content and documentation 2023/2024 passed

c810 introduction to health records content and documentationmanagement of record content - correct answer SOAP - correct answer subjective, objective, assessment, plan Quantitaive Analysis - correct answer - often called discharge analysis, is a review of the health record for completeness and accuracy. (quantity) qualitative analysis - correct answer When HIM personnel carefully review the quality and adequacy of record documentation and ensure that it is in accordance with the policies, rules, and regulations established by the facility; the standards of licensing and accrediting bodies; and government requirements (quality) discharge summaries are not required when - correct answer when the patients are in the hospital for 48 hours or less progress notes are - correct answer are chronological statements about the patient's response to treatment during his or her stay in the facility consultation - correct answer opinions of physicians with speciality training beyond general board certification such as oncolgoists, cardiologists, or dermatologists. attending physician - correct answer A medical doctor who is responsible for the overall care of a patient in a hospital or clinic setting. An attending physician may also supervise and teach medical students, interns, and residents involved in the patient's care. Health Record Life Cycle Retention - correct answer determining the schedule to be followed to proct and preserve active and inactive records Health Record Life Cycle disposition - correct answer the process of destroying the records once the end of the retention period has been reached overlap - correct answer patient has more than one record in more than one database overlay - correct answer one patient record is overwritten with another record PHI - correct answer Protected Health Information Advanced Directive (AD) - correct answer A legal document in which an individual gives written instructions expressing his or her wishes regarding health care in the event that person can no longer make those decisions. DNR - correct answer do not resuscitate External uses of secondary data - correct answer registries, publich reporting, research, and other purposes MEDLINE - correct answer - Medical Literature, Analysis, and Retrieval System Online- best-known database from National Library of Medicine. HIM professionals use this to locate artivles on HIM issues as well as articles on medical topics MEDPAR - correct answer acute-care hospital and skilled nursing facilities. Claims for all medicare claims NAPHSIS - correct answer National Association for public health statistics and information systems. manages the process of collecting vital statistics NCHS - correct answer national center for health statistics. provides a database of statistical health information to guide public health actions and policymaking