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An example of a primary data source for health care statistics is the ●●health record. ●●disease index. ●●MPI. ●●accession register. 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 regarding ●●the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed. ●●whether the severity of illness and/or intensity of service warranted acute level care. ●●whether a postoperative infection occurred and how it was treated. ●●the quality of follow-up care. The 2014 AHIMA Foundation's “Clinical Documentation Improvement Job Description Summative Report” identified that most clinical documentation improvement specialists report directly to the ●●Risk Management Department. ●●CFO. ●
●CEO. ●●HIM Department The master patient index must, at a minimum, include sufficient information to ●●uniquely identify the patient. ●●justify the patient's hospital bill. ●●list all physicians who have ever treated 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 the ●●Joint Commission accreditation manual. ●●hospital bylaws. ●●CARF manual. ●●Federal Register. 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 precision ●●data comprehensiveness ●●data granularity ●●data accuracy According to the HIPAA privacy rule, protected health information includes: ●●only electronic individually identifiable health information. ●●individually identifiable health information in any format stored by a health care provider or business associate. ●●non-individuially identifiable health information in any format stored by a health care provider. ●A retrospective review as part of quality improvement activities is conducted after the patient has been ●●cleared for surgery. ●●discharged. ●●released from the surgical recovery room. ●●admitted. ●only paper individually identifiable health information.
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 the ●●UHDDS. ●●facility's data dictionary. ●●MDS. ●●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 is ●●18-0000/01.