QUESTION: 33

In an acute care hospital, a complete history and physical may not be dictated for a new admission when

the patient is readmitted for a similar problem within 1 year.
the patient's stay is less than 24 hours.
the patient has an uneventful course in the hospital.
a legible copy of a recent H&P performed in the attending physician's office is available.

Answer(s): D

You are developing a complete data dictionary for your facility. Which of the following resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals?

Minimum Data Set
Uniform Hospital Discharge Data Set
Conditions of Participation
Federal Register

Answer(s): B

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QUESTION: 35

Sarasota Community Health Center has an approved cancer registry. A patient is readmitted for further treatment of a previously diagnosed cancer. The CTR should