QUESTION: 45

As the chair of a Forms Review Committee, you need to track the origin of data in a particular field and the security levels applicable to that field. Your best source for this information would be the

facility's data dictionary.
MDS.
Glossary of Health Care Terms.
UHDDS.

Answer(s): A

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QUESTION: 46

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

interval summary.
consultation report.
advance directive.
interdisciplinary care plan.

Answer(s): B

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QUESTION: 47

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

past medical history.
physical assessment.
chief complaint.
review of systems.

Answer(s): B

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QUESTION: 48

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

12 hours after admission.
24 hours after admission.
12 hours after admission or prior to surgery.
24 hours after admission or prior to surgery.

Answer(s): D

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Free HAAD RHIA Exam Braindumps (page: 13)

QUESTION: 45

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QUESTION: 48

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