Domain 3 exam.docx - Domain 3 exam HIT252 The health record...

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Domain 3 exam HIT252 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 ACCURACY Determine which of the following would be an example of an objective entry in the health record supplied by a health care practitioner is the PHYSICAL ASSESSMENT You would expect to find documentation regarding the assessment of an obstetric patient's lochia, fundus, and perineum on the postpartum record Determine which of the following is a form or view that is typically seen in the health record of a long- term care patient but is rarely seen in records of acute care patients? pharmacy consultation Currently, the enforcement of HIPAA Privacy and Security Rules is the responsibility of the Office for Civil Rights. The old practices of flagging records for deficiencies and requiring retrospective documentation add little or no value to patient care. You try to convince the entire health care team to consistently enter data into the patient's record at the time and location of service instead of waiting for retrospective analysis to alert them to complete the record. You are proposing point-of-care documentation. 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. Determine the best source for this information facility's data dictionary. Joint Commission does not approve of auto authentication of entries in a health record. Assess and determine the primary objection to this practice evidence cannot be provided that the physician actually reviewed and approved each report. Improving the specificity of clinical reports through the use of a physician query is a documentation goal that may be shared by the coding staff and this specialist: CDIP As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman that the H&P copy is acceptable as long as she documents any interval changes. Determine which of the following is a secondary data source that would be used to quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months? disease index There are seven criteria for high-quality clinical documentation. All of these elements are included EXCEPT covered (by third-party payer).

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