Complete this statement: "If it's not documented,
it wasn't done
There are many statutory provisions which address the
content of health records (false)
FALSE - there are very few.
What is the retention period for normal adult patient
What are the legal uses of the health record?
They form the backbone of every professional liability
action and are used to establish whether the standard of
care was met. They are also used in civil actions, such as
credentialing and disciplinary proceed
What are the types of specialized patient records covered in this chapter and their distinguishing
Specialized patient records include treatment for substance abuse or mental illness or in non-acute-care
settings, such as the patient's ho
According to DHHS, the health record must contain which of the following EXCEPT?
a history and physical examination dated not more than 45 days prior to admission
confirming an entry with written signature, initials, or computer-generated c
Billing a urinalysis during a prenatal visit unbundling
Submitting a bill for a service higher than the service that was rendered Upcoding
Investigates both Medicare and Medicaid fraud - Office of the Inspector General (OIG)
Easiest part of
Which scenario is NOT an example of informed consent? A mentally challenged adult agrees to have an
Which of the following is a difference between confidentiality and privacy? Privacy is the right to be left
alone or to control i
What is the difference between confidential and nonconfidential information for purposes of access to
patient-specific health information?
The difference is the manner in which the information is provided. Confidential information is provided
by the patie
What is the combination of planned functions directed toward prudent allocation of medical resources
and appropriate treatment management?
How would you define an adverse incident?
event or circumstance not consistent with normal ro