In preparation for an HER, you are conducting a total facility inventory of all forms currently used. You must name each form 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
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.
A good first step toward protecting the security of data contained in a health information computer system would be to A.establish a good record tracking system.B.define levels of security for different types of information, depending on sensitivity.C.provide remote terminals for improved access to the record.D.provide internet access to facility records.
In the number "99-0001" listed in a tumor registry accession register, what does the prefix "99" represent? A.the number of primary cancers reported for that patientB.the year the case was entered into the database of the registryC.the sequence number of the caseD.the stage of the tumor based upon the TNM system of staging
A risk manager needs to locate a full report of a patients fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the A.doctors’ progress notes.B.integrated progress notes.C.incident report.D.nurses’ notes.
For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the A.interdisciplinary patient care plan.B.discharge summary.C.transfer record.D.problem list.