Module 1.docx - Module 1 Health Data Content and Standards...

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Module 1: Health Data Content and Standards 1. Discharge summary documentation must include correct codes for significant procedures. a note from social services or discharge planning. significant findings during hospitalization. a detailed history of the patient. 2. 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 discharge summary. pathology report. recovery room record. operative report. 3. You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility's physicians' index. disease index. patient index. number control index. 4. Joint Commission does not approve auto authentication of entries in a health record. The primary objection to this practice is that tampering too often occurs with this method of authentication. electronic signatures are not acceptable in every state. evidence cannot be provided that the physician actually reviewed and approved each report. it is too easy to delegate use of computer passwords
5. One of the patients at your physician group practice has asked for an electronic copy of her medical record. Your electronic computer system will not allow you to accommodate this request. Chances are, you are NOT in compliance with meaningful use requirements. Joint Commission standards. Conditions of Coverage rules. the HIPAA Privacy Rule. 6. 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 use of abbreviations in the final diagnosis.

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