The best example of point-of-care service and documentation is
A. using an automated tracking system to locate a record.
B. using occurrence screens to identify adverse events.
C. doctors using voice recognition systems to dictate radiology reports.
D. nurses using bedside terminals to record vital signs.
You have been asked by a peer review committee to print a list of the medical record numbers of all patients who had CABGs performed in the past year at your acute care hospital. Which secondary data source could be used to quickly gather this information?
A. disease index.
B. physician index.
C. master patient index.
D. operation index.
As your acute care facility moves toward the adoption of an HER, your planning committee is trying to prioritize systems that will contribnute to patient safety. Your physicians have indicated readiness to enter data directly into the HER, and they acknowledge the need for decision support regarding drug dosages and contraindications. You think they are ready for a
A. computer-output-to-laser-disk system.
B. electronic medication administration record system.
C. electronic document management system.
D. computerized provider order-entry system.
A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statement regarding the history and physical is ture in this situation? Completion and charting of the HandP indicates.
A. noncompliance with Joint Commission standards.
B. compliance with Joint Commission standards.
C. compliance with Medicare regulations.
D. compliance with Joint Commission standards for nonsurgical patients.
As the privacy officer of your facility, you have been charged with developing policies and procedures for protecting the confidentiality and security of the clinical data collected in your computerized system. One of the first steps you will take is to judge the value of information processed by your system and classify it. Another step you will need to take is to
A. authorize access to information collected based on level of data sensitivity.
B. prevent all nonclinicians' access to any confidential information in the system.
C. establish firewalls to protect aggregate data collected within your facility.
D. establish passwords for all customers, both internal and external, who request access to the information in your system.
In preparing your facility for initial accreditation by Joint Commission, you are trying to improve the process of ongoing record review. All health record reviews are presently performed by a team of Him department personnel. The committee meets quarterly and reports to a Quality Management Committee. In reviewing Joint Commission standards your first recommended change is to
A. have more frequent committee meetings.
B. have the committee report to the Executive Committee.
C. have a physician perform all the reviews.
D. provide for record reviews to be performed by an interdisciplinary team of care providers.
A health record analyst needs to quickly compare all lab values during one hospitalization. The paper-based health record format best suited for this purpose is
A. problem-oriented.
B. source-oriented.
C. reverse chronological.
D. integrated.
Which interdisciplinary committee is most likely to be charged with the responsibility for monitoring trends in delinquent health record percentages?
A. Health Record Committee.
B. Utilization Review Committee.
C. Risk Management Committee.
D. Joint Conference Committee.
The foundation for communicating all patient care goals in long-term care settings is the
A. legal assessment.
B. labor and delivery record.
C. interdisciplinary patient care plan.
D. Uniform Hospital Discharge Data Set.
Quantitative and qualitative reviews performed on patient records by medical record personnel in either a skilled nursing facility or inpatient psychiatiry facility are generally in the form of
A. retrospective deficiency analysis.
B. special study audits.
C. concurrent chart review.
D. occurrence screening.
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