RHIA Exam - Health Data Content & Standards

Document Content and Description Below

In preparation for an EHR, you are conducting a total facility inventory of inventory of all forms currently used. You must name each for bar coding and indexing into a document management system. The... unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is: A. recovery room record B. pathology report C. operative report D. discharge summary - B (C and D) Although a gross description of tissue removed may be mentioned on the operative note or discharge summary, only the pathology report will contain a microscopic description. Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS, but NOT in the UHDDS would be: A. personal identification. B. cognitive patterns. C. procedures and dates. D. principal diagnosis. - B Answers A, C, and D represent items collected on Medicare inpatients according to UHDDS requirements. Only B represents a data item collected more typically in long-term care settings and required in the MDS. 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 the: A. prohibited use of any abbreviations. B. flagrant use of specialty-specific abbreviations. C. use of prohibited or "dangerous" abbreviations. D. use of abbreviations used in the final diagnosis. - C The Joint Commission requires hospitals to prohibit abbreviations that have caused confusion or problems in their handwritten form, such as "U" for unit, which can be mistaken for "O" or the number "4". Spelling out the unit is preferred. In the number "10-0001" listed in a tumor registry accession register, what does the prefix "10" represent? [Show More]

Last updated: 1 year ago

Preview 1 out of 27 pages