Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
WGU BDV1 Module 4
WGU BDV1 Mod 4 Health Data Management across the continuum (AHIMA C2V3)
| Question | Answer |
|---|---|
| A health record available electronically allowing communication across providers and permitting real-time decision making. | Electronic Health Record (EHR) |
| A health record that uses components of both paper and electronic systems. | Hybrid Health Record |
| What are the 2 parts of a health record? | Clinical and Adminstrative |
| Which of the following is a health record not used for? (Patient Care, Provider Commication, Evaluating Care, Disease Management, Substantiating Billing Claims, Legal Interests) | Disease Management |
| Which of the sources for standards documentaiton is missing? (Facility Standards, Licensure Standards, Accreditation Standards) | Government Reimbursement Programs |
| Documents the patient's current complaints and symptoms and lists past medical, personal, and family history. | Medical History |
| Represents the attending Phy's assessment of the patient's current health status. | Physical Exam Report |
| Documentaiton of clinical ovservations usually found in an acute care setting. | Progress Note |
| This is assumed when a patient voluntarily submits to treatment. | Implied Consent |
| This is in effect when consent is given either spoken or written. | Expressed Consent |
| This document notes any preoperative medication and response to it, the anesthesia administered with dose and method of administration, duration of administration, and patient's vital signs while under anesthesia. | Anesthesia Report |
| This document describes the surgical procedures performed on the patient and is dictated ot written by the surgeon following the procedure. | Operative Report |
| This document includes the postanesthesia note, nurses's note regarding patient's condition, surgical site, vital signs, fluids given, and monitoring. | Recovery Room Report |
| This document provides a concise account of the patient's illness, course of treatment, response to treatment, and condition at the time of discharge from the hospital. | Discharge Summary |
| What documents the continuity of care, supports activities for medical staff review, and concise information used to answer requests for information by authorized indivudlas or entities. | Discharge Summary |
| This is obtained from patients or legal representatives before providing care or services in emergency situations. | Consent to treatment |
| Privacy legislation has made this document a matter of facility choice. | Consent to treatment |
| The privacy rule requires providers to secure the patient's written acknowledgement that he or she has received this document. | Notice of Privacy Practices (NPP) |
| This document allows the healthcare facilty to verbally disclose or send health informaiton to other organizations (other than those provided as part of HIPAA). | Authorization to disclose information |
| This is a legal document that contains the patient's choice for legal representative for healthcare purposes. | Advanced Directive |
| These physician orders should be consistent with the patient's advanced directives. | Do Not Resuscitate (DNR) and Do Not Attempt Intubation (DNI) |
| This regulation includes acknowledgment forms used to document the patient received information about their rights while a patient. | Patient's Bill of Rights |
| This is another name for the Patient's Bill of Rights. | Medicare Conditions of Participation |
| What term refers to state or county regulations that healthcare facilities must meet to be permtted to provide care? | Licensure |
| Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment actin steps? | Care Plan |
| An APGAR Score is likely found in what type of chart? | Newborn |
| This organization issues specific health informaiton standards for acute care hopitals. | JCAHO |
| This organization issues specific health informaiton standards for rehab hospitals | CARF |
| Ambulatory care records typically includes this document to facilitate ongoing patient care management, but it isn;t typically included on acute care records. | Problem List |
| This ambulatory care document describes current and past illnesses and conditions as well as procedures a patient has undergone. | Problem List |
| Some physican practices use this to collect past medical history informaiton from the patient. | Patient history questionnaire |
| Name an accreditation agency that may have documentation standards for an ambulatory care setting? | Accreditation Association for Ambulatory Health Care (AAAHC) |
| Name an accreditation agency that may have documentation standards for an ambulatory care setting? | JCAHO |
| Name an accreditation agency that may have documentation standards for an ambulatory care setting? | American Osteopathic Association (AOA) |
| Name an accreditation agency that may have documentation standards for an ambulatory care setting? | National Committee for Quality Assurance (NCQA) |
| Which type of record might include sexual practices? | Obstetric/Gynecologic |
| This care plan format is used by SNF's and includes the MDS. | Resident assessment instrument (RAI) |
| The RAI includes MDS, triggers, utilization guidelines, and _______ ________ ________. | Resident assessment protocols (RAPs) |
| Medicare uses this form in a long term facility to determine reimbursement. | Minimum Data Set (MDS) |
| Medicare certified home health agencies use this standardized patient assessment insrutment for the plan of care and reimbursement. | Outcomes and Assessment Informaiton Set (OASIS) |
| Care provided to terminally ill patients and supportive services to patients and families. | Palliative Care |
| This document is completed shortly after admisison and upon discharge to an inpatient rehab facility. | Patient assessment instrument (PAI) |
| Medicare requires this for various settings of care for End-Stage Renal Disease. | Conditions of Coverage |
| An electronic, universally available, lifelong resource of health information needed by individuals to make health decisions. | Personal Health Record |
| Which type of health record contains information about care provided prior to arrival at a healthcare setting and documentaiton of care provided to stabilize the patient? | Emergency Care |
| Patient history quesionnaires, problem lists, diagnostic test results, and immunization records are found in which type od record? | Ambulatory Care |
| Ambulatory surgery record contains information most similar to ___________. | Hospital operative records |
| Which standardized tool is used to assess Medicare-certified rehab facilities? | Patient assessment instrument (PAI) |
| Records in which setting would not include an interdisciplinary care plan? | Ambulatory care |
| Portions of a treatment record may be maintained in a patient's home for which settings of care? | Home Health and End-Stage Renal Disease |
| Paper records may require thenning in which two settings? | Long Term Care and Correctional Serevices |
| In 2004 JCAHO implemented a new survey process called Shared Visions-New Pathways to bring what changes? | Continuous improvement and compliance, streamlined survey paperwork, midcycle reviews, sentinel events monitoring, and tracer methodology |
| Accreditation manuals often include documentation standards in a section called what? | Management of Information |
| The American Osteopathic Association (AOA) originally began for what purpose? | Ensure the quality of residency programs for their doctors. |
| Which of these services are not accredited by CARF? (Medical Rehab, End-Stage Dialysis, Assisted Living, Behavorial Health, Adult day care, employment and community centers) | End-Stage Dialysis Centers |
| What organization accreditates Managed Care and Preferred Provider Organizations starting in 1991? | National Committee for Quality Assurance (NCQA) |
| Organizations receiving funding for services to Medicare patients must comply with what? | Medicare Conditions of Participation |
| The Medicare Conditions of Participation requires that Medical History and Physical exam be completed no more than _____ days before or _____ hours after admission. | 30, 24 |
| What is the correct section of the medical record to contain Vital Signs? | Objective section of a SOAP note |
| What is the correct section of the medical record to contain the marital status and occupation? | Social history of a Medical History |
| What is the correct section of the medical record to contain the referral of the patient to a physical therapist for treatment? | Plan section of a SOAP note |
| What is the correct section of the medical record to contain the Systematic Inventory? | Review of systems portion of a Medical History |
| What is the correct section of the medical record to contain the directions for follow up? | Discharge Summary |
| What organization is the source of documentation standards or guidelines for Long Term Care facility? | Joint Commission |
| What organization is the source of documentation standards or guidelines for Osteopathic residency programs? | AOA |
| What organization is the source of documentation standards or guidelines for Ambulatory care? | AAAHC |
| What organization is the source of documentation standards or guidelines for Rehabilitation hospital? | CARF |
| What organization is the source of documentation standards or guidelines for Managed care assessment of in-plan providers? | NCQA |
| Which of the medical record form/report summarizes the patient's medical and surgical conditions? | Problem List |
| Which of the medical record form/report is a component of the medical history? | Chief complaint or reason for visit |
| Which of the medical record form/report describes surgical procedures performed? | Operative Report |
| Which of the medical record form/report is a written opinion provided by one physician to another? | Consultation Report |
| Which of the medical record form/report an be integrated or source-oriented? | Progress Note |
| In a SOAP Note, what is the "S" represent? | Subjective: Patient's complaints and comments |
| In a SOAP Note, what is the "O" represent? | Objective: Physical findings and laboratory data |
| In a SOAP Note, what is the "A" represent? | Assessment: Diagnosis and impression |
| In a SOAP Note, what is the "P" represent? | Plan: Medication, therapy, referral, consultation, and patient education |
Created by:
drward@myway.com
Popular Medical sets