HIT252 - Domain 3 Exam.docx - Domain 3 Exam The performance...

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Domain 3 ExamThe performance of ongoing record reviews is an important tool in ensuring data quality. These reviews evaluatethe overall quality of documentation in the record.adverse effects and contraindications of drugs utilized during hospitalization.quality of care through the use of preestablished criteria.potentially compensable events.CORRECT"Adverse effects and contraindications of drugs utilized during hospitalization" and "quality of care through the use of preestablished criteria" deals with issues directly linked to quality of care reviews. Potentially compensable eventsdeals with risk management. Only "the overall quality of documentation in the record" points to a review aimed at evaluating the quality of documentation in the health record. Joint Commission does not approve auto authentication of entries in a health record. The primary objection to this practice is that evidence cannot be provided that the physician actually reviewed and approved each report.tampering too often occurs with this method of authentication.electronic signatures are not acceptable in every state.it is too easy to delegate use of computer passwords.CORRECTAuto authentication is a policy adopted by some facilities that allow physicians to state in advance that transcribed reports should automatically be considered approved and signed (or authenticated) when the physician fails to make corrections within a preestablished time frame (e.g., "Consider it signed if I do not make changes within 7 days."). Another version of this practice is when physicians authorize the HIM department to send weekly lists of unsigned documents. The physician then signs the list in lieu of signing each individual report. Neither practice ensures that the physician has reviewed and approved each report individually. During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day 4 of hospitalization, there was one missed dose of insulin. What type of review is this clerk performing? CORRECT
Domain 3 Exam There are seven criteria for high-quality clinical documentation. All of these elements are included EXCEPT

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