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Registered Health Information Administrator (RHIA) Questions 46–50 (page: 11)

You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate that due to some heat irregularities, he many not be a good surgical risk. Because of your knowledge of COP regulations, you expect that a(n)_______________ will be added to his health record

An example of objective entry in the health record supplied by a health care practitioner is the

You have been appointed as chair of the Health Record Committee at a new hospital. Your committee has been asked to recommend time-limited documentation standards for inclusion in the Medical Staff Bylaws, Rules and Regulations. The committee documentation standards must meet the standards of both the Joint Commission and the Medicare Conditions of Participation. The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report be should be set at

A pathologist on the Health Record Committee asks about the time requirement for reporting a provisional diagnosis when an autopsy is performed. You respond confidently that this information must be on the health record within

A surgeon on the Health Record Committee voices a concern that, although he has been told that the operative report is to be dictated immediately after surgery, he has often had to deal with the problem of transcription backlog which prevented the report from getting on the health record in a timely manner. Your advice to this doctor is that when a known backlog exists, he should