Delegated use of computer key by radiology secretary

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delegated use of computer key by radiology secretary a unique identification code entered by the person making the report written signature of the provider of care identifiable initials of a nurse writing a nursing note.
18. A key data item you would expect to find recorded on an ER record but would probably NOT see in an acute care record is the instructions for follow-up care.
19. Which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record?
20. A data item to include on a qualitative review checklist of newborn inpatient health records that
21. You are developing a complete data dictionary for your facility. Which of the following resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals? Conditions of Participation Federal Register Minimum Data Set Uniform Hospital Discharge Data Set
22. As a new HIM manager of an acute care facility, you have been asked to update the facility's policy for a physician's verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualifications of those individuals in your facility who have been authorized to record verbal orders. For this information, you will consult the policy and procedure manual.
23. A health care facility has made a decision to destroy computerized data. AHIMA recommends which one of the following as the preferred method of destruction for computerized data?
24. In the computerization of forms, good screen-view design, along with the options of alerts and alarms, makes it easier to ensure that all essential data items have been captured. One essential item to be captured on the physical exam is the general appearance as assessed by the physician.
25. Which of the following should NOT be included in the documentation of record destruction? statement that records were destroyed in the normal course of business signature of the individuals supervising and witnessing the destruction dates not covered in destruction method of destruction
26. You are the office manager at a large group practice. One of the physicians at your practice has asked

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