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CCA TESTProtected health information includesindividually identifiable health information in any format stored by a health care provider or business associate. The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely include checking for documentation regardingwhether the severity of illness and/or intensity of service warranted acute level care. the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed. whether a postoperative infection occurred and how it was treated. the quality of follow-up care. he 2014 AHIMA Foundation's “Clinical Documentation Improvement Job Description Summative Report” identified that most clinical documentation improvement specialists report directly to theCEO. Risk Management Department. CFO. HIM Department The master patient index must, at a minimum, include sufficient information tolist all physicians who have ever treated the patient. justify the patient's hospital bill. uniquely identify the patient. summarize the patient's medical history. In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is thehospital bylaws. Federal Register. Joint Commission accreditation manual. CARF manual. The health record states that the patient is a female, but the registration record has the patient listed as male. Which of the following characteristics of data quality has been compromised in this case?data granularity
data accuracy data precision data comprehensiveness Protected health information includesindividually identifiable health information in any format stored by a health care provider or business associate. individually identifiable health information in any format stored by a health care provider. only paper individually identifiable health information. only electronic individually identifiable health information. A retrospective review as part of quality improvement activities is conducted after the patient hasbeencleared for surgery. discharged. released from the surgical recovery room. admitted. As the chair of a Forms Review Committee, you need to track the field name of a particular data field and the security levels applicable to that field. Your best source for this information would be theMDS. UHDDS. facility's data dictionary. glossary of health care terms. The first patient with cancer seen in your facility on January 1, 2018 was diagnosed with colon cancer with no known history of previous malignancies. The accession number assigned to this patient is18-0000/01.