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The Conditions of Participation requires that the medical staff bylaws, rules, and regulations address the status of consultants. Which of the following reports would normally be considered a consultation?

  1. tissue examination done by the pathologist
  2. impressions of a cardiologist asked to determine whether patient is a good surgical risk
  3. interpretation of a radiologic study
  4. technical interpretation of electrocardiogram

Answer(s): B



The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely to include checking for documentation regarding

  1. the presence or absence of such items as preoperative and postoperative diagnosis description of findings, and specimens removed.
  2. whether a postoperative infection occurred and how it was treated.
  3. the quality of follow-up care.
  4. whether the severity of illness and/or intensity of service warranted acute level care.

Answer(s): A



In your facility it has become critical that information regarding patients who are transferred to the oncology unit be sent to an outpatient scheduling system to facilitate outpatient appointments. This information can be obtained most efficiently from

  1. generic screens used by record abstractors.
  2. Disease index.
  3. R-ADT system.
  4. Indicator monitoring program.

Answer(s): C



In your facility, the health care providers from every discipline document progress notes sequentially on the same form. Your facility is utilizing

  1. integrated progress notes.
  2. interdisciplinary treatment plans.
  3. source-oriented records.
  4. SOAP notes.

Answer(s): A






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