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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.In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the commission's national patient safety goals, the focus has shifted to theuse of abbreviations in the final diagnosis.prohibited use of any abbreviations.use of prohibited or "dangerous" abbreviations.flagrant use of specialty-specific abbreviations.CORRECTAs part of its National Patient Safety Goals initiative, the Joint Commission required hospitalsto prohibit abbreviations that have caused confusion or problems in their handwritten form, such as "U" for unit, which can be mistaken for "O". Spelling out the word "unit" is preferred.One of the Joint Commission National Patient Safety Goals (NSPGs) requires that health care organizations eliminate wrong-site, wrong-patient, and wrong-procedure surgery. In order to accomplish this, which of the following would NOT be considered part of a preoperative verification process?Mark the surgical site.Review the medical records and/or imaging studies.Follow the daily surgical patient listing for the surgery suite if the patient has been sedated.Confirm the patient's true identity.CORRECT"Confirm the patient's true identity," "mark the surgical site," and "review the medical records and/or imaging studies"—these are usually in the protocol to prevent wrong site, wrong patient, or wrong surgery. The correct answer is following the daily surgical patient listing—that choice would NOT be an appropriate step in making sure you have the correct identity ofthe patient, the correct site, or the correct surgery.
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?utilization reviewlegal reviewqualitative reviewquantitative reviewINCORRECTQuantitative analysis involves checking for the presence or absence of necessary reports and/or signatures, while qualitative analysis may involve checking documentation consistency, such as comparing a patient's pharmacy drug profile with the medication administration record.As part of a quality improvement study, you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records. The best place in the record to locate this information is thepostpartum record.