Health Data Content

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A coder who needed to locate the microscopic description of tissue excised during surgery would be most likely to find this information within the... ...pathology report.
You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility's... ...disease index.
A foundation for communicating all patient care goals in long-term care settings is the... ...interdisciplinary patient care plan.
For each report of care rendered to a patient, the health record entry should include the date plus the provider's name and ... ...discipline.
This is a resource that will be most helpful in providing standard definitions for data commonly colledted in acute care hospitals... ...Uniform Hospital Discharge Data Set.
An example of an objective entry in the health record supplied by a health care practitioner is the... ...physical assessment.
One of the essential item to be captured on the physical exam is the... ... objective survey of body systems.
Joint commission standards require that a complete history and physical be documented on the health records of operative patients. Does this report carry a time requirement?... ...yes, prior to surgery.
Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of ... ...qualitative analysis.
The lack of a discharge order may indicate that the patient left against medical advice. If this situation occurs, you would expect to see the circumstances of the leave... ... documented in both the progress notes and the discharge summary.
Accreditation by Joint Commission is a voluntary activity for a facility and it is ... ...required for reimbursement of certain patient groups.
This index might be protected from unauthorized access through the use of unique identifier codes assigned to members of the medical staff... ...physician index.
For inpatients, the first data item collected of a clinical nature is usually... ...the admitting diagnosis.
The ownership of the information contained in the physical medical/health record is considered to belong to the ... ...patient.
HIM professionals are bound to protect the confidentiality of patient information under the... ...AHIMA's Code of Ethics.
Internal disclosures of patient information for patient care purposes should be granted... ...on a need to know basis.
The process of comparing the outcomes of HIM abstracting functions at your facility with those of comparable departments of superior performance in other health care facilities to help improve accuracy and quality is referred to as... ... benchmarking.