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Content and structure standards
Providing information about the patient's insurance coverage
Ensuring the continuity of future care
Providing information to support the activities of the medical staff review committee
Providing concise information that can be used to answer information requests
Consent to treatment
The problem list is an index
The initial plan
The SOAP form of progress notes
Reason for admission
Reason for encounter
Activities of daily living
Transfer or referral
Release of information
Patients rights acknowledgement
Admitting physical evaluation
Postacute care unit record
High blood pressure
Congestive heart failure
Code asthma with status asthmaticus
Code asthma with acute exacerbation
Query the physician for more detail about asthma
Fever, cough, shortness of breath
Cough, shortness of breath
Pneumonia, cough, shortness of breath
Medical decision making
Levels of services
Retrospectively review each patient's medical record to make sure history and physical are present
Review each patient's medical report concurrently to make sure history andphysical are present and meet the accreditation standards
Establish a process to review medical records immediately on discharge
Do a review of records for all patients discharged in the previous 60 days
Discuss the problem with the hospital CEO
Call the Joint Commission
Contact other hospitals to see what methods they use to ensure compliance
Drop the issue because non-compliance is always a problem
To serve as a source for case study information
To determine whether the documentation supports the provider's claim for reimbursement
To provide healthcare services
To determine whether standards of care are being met
Joint Commission Accreditation Standards
Accreditation Association for Ambulatory Healthcare Standards
Conditions of Participation
Outcomes and Assessment Information Set
Recovery room record
The record is not in compliance as the physical exam must be completed within 24 hours of admission.
The record is not in compliance as the physical exam must be completed within 48 hours of admission.
The record is in compliance as the physical examination must be completed within 48 hours.
The record is in compliance because the physical examination was completed within 72 hours of admission.
Report of history and physical examination
Internal DRG audits
Routinely send out a fourth notice
Post the hospital policy in the emergency department
Consult with the physician in charge of the on-call doctors for suggestions on how to improve response to the current notices
Call the Joint Commission
Assign codes to an incomplete record with organizational policies in place to ensure codes are reviewed after the records are complete
Follow-up on and monitor identified problems
Evaluate and trend diagnoses and procedures code selections
Report data quality review results to organizational leadership, compliance staff, and the medical staff
10022; 19295-LT; 76942
37.81, 37.73, 37.71
Atrial fibrillation (427.31)
Atrial flutter (427.32)
Paroxysmal supraventricular tachycardia (427.0)
Sick sinus syndrome (SSS)(427.81)
Combined right and left (88.54)
Other and unspecified (88.57)
661.01, V27.0, 74.1
661.21, V27, 74.1
Resource-based relative value scale system
Long-term care drugs
Resource utilization drugs
Local coverage determination from Medicare
American Medical Association's CPT Assistant newsletter
American Hospital Association's Coding Clinic
CMS Web site
Report the remaining tests using individual test codes accordinto to CPT.
Do not report the remaining individual test codes.
Report only those test codes that are part of the panel.
Do not report a test code more than once regardless if the test was performed twice.
Outpatient Perspective Payment System (OPPS)
National Correct Coding Inditiative (NCCI)
Ambulatory Payment Classifications (APCs)
Comprehensive Outpatient Rehab Facilities (CORFs)
AMA's CPT Assistant
AHA's Coding Clinic for HCPCS
AHA's Coding Clinic for ICD-9-CM
National Correct Coding Initiative (NCCI)
ICD-90CM diagnosis and procedure codes
Resource utilization groups
Chart deficiency system
Chart tracking system
Chart abstracting system
Unauthorized access to a system
Loss of data
Presence of a virus
Successful completion of a backup
It is a system or combination of systems that supports an access control policy between two networks.
The most common place to find a firewall is between the healthcare organization's internal network and the Internet.
Firewalls are effective for preventing all types of attacks on a healthcare system.
A firewall can limit internal users from accessing various portions of the Internet.
Optical character recognition
Electronic data interchange
Device to enter data
Protocol for describing data
Program to exchange data
Yes; HIPAA only requires the current records to be produced for the patient.
Yes; this is hospital policy for which HIPAA has no control
No; the records from the previous hohspital are considered part of the designated record set and should be given to the patient.
No; the records from the previous hospital are not included in the designated record set but should be released anyway.
Provide the medical records in paper format
Burn another CD since this is hospital policy
Provide the patient with both paper and CD copies of the medical record
Review the CD copies with the patient on a hospital computer
The right individuals to control access to their personal health information
The protection of healthcare information from damage, loss, and unauthorized alteration
The expectation that personal information shared by an individual with healthcare provider during the course of care will be used only for its intended purpose
The expectation that only individuals with the appropriate authority will be allowed to access healthcare information
Clinical coding principals
Federal and state confidentiality laws
Human resource management
HIPAA does not allow a patient's name to be announced in a waiting room.
There is no HIPAA violation for announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice.
HIPAA allows only the use of the patient's first name.
HIPAA requires that patients be given numbers and only the number be announced.
Review the subpoena to determine what document must be produced
Review the subpoena and notify the hospital administrator
Consult with the hospital legal counsel
Review the subpoena and alrt the hospital risk-management department
Only health records in paper format
Only health records in electronic format
Health records in paper or electronic format
Health records in any format
Allow Dr. Smith to see the records becausse he was the daughter's guardian at the time of the tonsillectomy.
Call the hospital administrator for authorization to release the record to Dr. Smith since he is on the medical staff.
Inform Dr. Smith that he cannot access his daughter's health record without her signed authorization allowing him access to the record.
Refer Dr. Smith to Dr. Jones and release the record if Dr. Jones agrees.
Consider the values and obligations of others; consider the choice that are both justified and not justified; determine the facts; identify prevention options.
Consider the choices that are both justified and not justified; consider the values and obligations of others; identify prevention options; determine the facts.
Determine the facts; consider the choices that are both justified and not justified; consider the values and obligations of others; identify prevention options.
Determine the facts; consider the values and obligations of others; consider the choices that are both justified and not justified; identify prevention options.
Ignore the state law and follow the HIPAA standard
Follow the state law and ignore the HIPAA standard
Comply with both the state law and the HIPAA standard
Ignore both the state law and the HIPAA standard and follow relevant accreditation standards
No information due to the highly sensitive nature of his illness
Admission date and location in the facility
General condition and acknowledgement of admission
Location in the facility and diagnosis