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10 Cards in this Set

  • Front
  • Back
What five purposes does the health record serve
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
Name an advantage of an electronic health record
many users are able to access the record at the same time
Name the nonfederal organization that requires reporting of data collected from the health record
The Joint Commission - TJC
List five elements required by the UHDDS
Personal identification
Race and ethnicity
Hospital Identification number
Admission date
type of admission
Discharge date
attending physician identification
Where in the record would you find chief complaint?
first? ER report
What is the most important definition a coder should know?
principal diagnosis
What determines an MS-DRG?
the principal diagnosis and the principal procedure
List 5 reasons a secondary diagnosis might be reported
clinical evaluation
therapeutic treatment
diagnostic procedure
extended length of hospital stay/or increased/or nursing care monitoring
List 6 reasons a provider may need to be queried
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
Which report must be on the record within 24 hours?
the operative report