Health Data Content and StandardsReview Quiz 1Discharge summary documentation must include:A.a detailed history of the patientB.a note from social services or discharge planning.C.significant findings during hospitalization.D.correct codes for significant procedures.significant findings during hospitalization.
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:
You have been asked to identify every reportable case of cancer from the previous year. A key resource will bethe facility's:
Disease indexJoint Commission does not approve auto authenticationof entries in a health record. The primary objection to this practice is that
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 withA.Conditions of Coverage rules.B.meaningful use requirementsC.Joint Commission standardsD.the HIPAA Privacy Rulemeaningful use requirements