The information security officer is revising the policies at your rehabilitation facility for handling all patient clinical information. The best resource for checking out specific voluntary accreditation standards and guidelines is the:
A. Conditions of Participation for Rehabilitation Facilities.
B. Medical Staff Bylaws, Rules, and Regulations.
C. Joint Commission
D. CARF manual
Answer: D. CARF manual
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Health Data Content and Standards
- Medicare rules state that the use of verbal orders should be infrequent and used only when the orders cannot be written or given electronically. In addition, verbal orders must be:
- A qualitative analysis of OB records reveals a pattern of inconsistent data entries when comparing documentation of the same data elements captured on both the prenatal form and labor and delivery form. The characteristic of data quality that is being compromised in this case is data:
- Before making recommendations to the Executive Committee regarding new physicians who have applied for active membership, the Credentials Committee must query the:
- The new electronic system recently purchased at your physician practice allows for e-prescribing, exchange of data to a centralized immunization registry, and it allows your physicians to report on key clinical quality measures. In all likelihood, your practice has succeeded in choosing a (an)
- A primary focus of screen format design in a health record computer application should be to ensure that:
- In preparation for an upcoming site visit by Joint Commission, you discover that the number of delinquent records for the preceding month exceeded 50% of discharged patients. Even more alarming was the pattern you noticed in the type of delinquencies. Which of the following represents the most serious pattern of delinquencies? Fifteen percent of delinquent records show:
- Using a template to collect data for key reports may help to prompt caregivers to document all required data elements in the patient record. This practice contributes to data:
- As the Coding Supervisor, your job description includes working with agents who have been charged with detecting and correcting overpayments made to your hospital in the Medicare Fee for Service program. You will need to develop a professional relationship with:
- Which of the following is a secondary data source that would be used to quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months?
- Stage I of meaningful use focused on data capture and sharing. Which of the following is included in the menu set of objectives for eligible hospitals in this stage?
- Based on the following documentation in an acute care record, where would you expect this excerpt to appear?
- Select the appropriate situation for which a final progress note may legitimately be substituted for a discharge summary in an inpatient medical record.
- As the Compliance Officer for an acute care facility, you are interested in researching recent legislation designed to provide significant funding for health information technology for your next committee meeting. You begin by googling:
- As supervisor of the cancer registry, you report the registry's annual caseload to administration. The most efficient way to retrieve this information would be to use:
- Which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record?
- The 2014 AHIMA Foundation's "Clinical Documentation Improvement Job Description Summative Report" identified that most Clinical Documentation Improvement Specialists report directly to the:
- Accreditation by Joint Commission is a voluntary activity for a facility and it is:
- Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of
- 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
- As a trauma registrar working in an emergency department, you want to begin comparing your trauma care services to other hospital-based emergency departments. To ensure that your facility is collecting the same data as other facilities, you review elements from which data set?
- Though you work in an integrated delivery network, not all systems in your network communicate with one another. As you meet with your partner organizations, you begin to sell them on the concept of an important development intended to support the exchange of health information across the continuum within a geographical community. You are promoting that your organization join a:
- Which method of identification of authorship or authentication of entries would be inappropriate to use in a patient's health record?
- Which of the following services is LEAST likely to be provided by a facility accredited by CARF?
- In your facility, the health care providers from every discipline document progress notes sequentially on the same form. Your facility is utilizing