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10 Cards in this Set
- Front
- Back
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What five purposes does the health record serve
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1.Describes the patient's health history
2.Serves as a method for clinicians to communicate regarding the plan of care for the patient 3.Serves as a legal document of care and services provided 4.Serves as a source of data 5.Serves as a resource for healthcare practitioner education |
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Name an advantage of an electronic health record
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many users are able to access the record at the same time
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Name the nonfederal organization that requires reporting of data collected from the health record
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The Joint Commission - TJC
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List five elements required by the UHDDS
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Personal identification
DOB Sex Race and ethnicity Residence Hospital Identification number Admission date type of admission Discharge date attending physician identification |
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Where in the record would you find chief complaint?
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first? ER report
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What is the most important definition a coder should know?
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principal diagnosis
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What determines an MS-DRG?
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the principal diagnosis and the principal procedure
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List 5 reasons a secondary diagnosis might be reported
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clinical evaluation
therapeutic treatment diagnostic procedure extended length of hospital stay/or increased/or nursing care monitoring |
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List 6 reasons a provider may need to be queried
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Clinical indicators of a diagnosis but no documentation of the condition
2. Clinical evidence for higher degree of specificity 3. A cause and effect relationship between two conditions or organisms 4. An underlying cause when admitted with symptoms 5. Only the treatment is documented 6. Present on admission (POA) indicator status is unknown or unclear |
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Which report must be on the record within 24 hours?
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the operative report
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