Parker is a type I diabetic with hypertension that is currently controlled with medication. Parker was admitted through the ED for an emergency appendectomy. Following surgery, the patient developed an infection at the wound site that was treated with antibiotics. When making decisions about sequencing the codes for this case, the coder should rely on definitions found in the
A. UHDDSFor a health care facility to meet its document destruction needs, the certificate of destruction should include all but which one of the following elements?
A. unique and serialized transaction numberYou 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?
A. Minimum Data SetDana, the transcription supervisor, has prepared an evaluation for one of her employees. As the evaluation is reviewed by the HIM director, he notes that the employee received an overall rating of "needs improvement." After reading the comments, the director asks Dana to document specific performance improvement recommendations. Dana is unable to do so because she is basing her assessment on her memory of incidents that have occurred over the past year. The director suggests that Dana reassess the employee's evaluation because, ideally, performance appraisals should occur
A. at the end of the 90 day probationary period.According to AHIMA and AHA guidelines, which of the following would be an acceptable authorization for release of information from the medical record of an adult, mentally competent patient hospitalized from 4/16/2007 to 5/10/2007? An authorization dated
A. 7/10/2007 and presented 7/15/2007The physician who performed the highest number of services overall last Tuesday was Doctor The physicians at Sunset Shore Clinic reported the following statistics last Tuesday.

Sally had three babies in 4 years and she considered that more than enough. During her hospitalization for her third delivery, Sally had a sterilization procedure performed. When the record is coded, the V-code for sterilization, V25.2 is
A. not used.The HIM Department is located in a teaching hospital and provides record access 24 hours a day, 7 days a week. To secure the file area and continue to maintain accessibility, the department director should
A. be on call during the evening hours.The following data elements are in a limited data set file being released. Which data element is in the file in error, in that it is PHI?
A. zip codeWhich 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 a acute care patients?
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