Domain 3 CCA Exam
You have 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 should be set at 24 hours after admission or prior to surgery. 24 hours after admission. 12 hours after admission. 12 hours after admission or prior to surgery.
24 hours after admission or prior to surgery 24 hours after admission or prior to surgery. This time requirement complies with both Joint Commission and COP standards.
You recommend that the staff routinely check to verify that a summary on each patient is provided to the attending physician so that he or she can review, update, and recertify the patient as appropriate. The time frame for requiring this summary is at least every 60 days. month. 90 days. week.
60 days This 60-day time frame is often referred to as the patient's certification period. Recertification can continue every 62 days until the patient is discharged from home health services.
Determine the data item to include on a qualitative review checklist of newborn inpatient health records that need NOT be included on adult records time and means of arrival. chief complaint. APGAR score. condition on discharge.
APGAR score APGAR stands for Appearance, Pulse, Grimace, Activity, and Respiration. This is the test used to assess a baby's health at birth. APGAR scores are part of newborn documentation. The wrong answers: 1) Chief complaint and time and 2) means of arrival are items that should be documented on any inpatient record. 3) Condition on discharge reflects a data item you would expect to find on ER records.
AHIMA guidelines state a query should be considered when health record documentation includes which of the following? Conflicting, imprecise, incomplete, ambiguous, or inconsistent documentation A diagnosis without an underlying clinical validation Unclear POA (present on admission) indicators All of these
All of these *AHIMA guidelines state that a query should be considered when health record documentation includes the following: *Conflicting, imprecise, incomplete, ambiguous, or inconsistent documentation *Associated clinical indicators related to a specific condition *A diagnosis without an underlying clinical validation *Unclear POA (present on admission) indicators
Determine which of the following is least likely to be identified by a deficiency analysis technician? missing discharge summary X-ray report charted on the wrong record need for physician authentication of two verbal orders Discrepancy between postoperative diagnosis by the surgeon and pathology diagnosis by the pathologist represents a more in-depth review
Discrepancy between postoperative diagnosis by the surgeon and pathology diagnosis by the pathologist represents a more in-depth review Discrepancy between postoperative diagnosis by the surgeon and pathology diagnosis by the pathologist represents a more in-depth review dealing with the quality of the data documented
A set of standards that makes sharing clinical and administrative data possible between healthcare entities by allowing different software packages to interface with one another is known as HL-7. QRDA. CDA. CCD
HL-7 Health Level Seven (HL-7) is a set of standards that makes sharing clinical and administrative data possible between healthcare entities by allowing different software packages to interface with one another. The Continuity of Care Document (CCD) is built using HL7 Clinical Document Architecture (CDA) elements and contains data that is defined by the Continuity of Care Record (CCR). It is used to share summary information about the patient within the broader context of the personal health record. CDA is a Clinical document architecture using an XML standard for building any Clinical document. Quality Reporting Document Architecture (QRDA) is a type of Clinical Document Architecture (CDA)-based standard for reporting patient quality data for one or more quality measures.
Before submitting a query, stop and consider the appropriateness. Which of the following would be considered inappropriate in a query? Being direct in what is being asking without being leading Always provide the provider with multiple answer options Always include an "out" such as "unable to be determined" Including ICD-10-CM/PCS codes, code details, or coding guidelines
Including ICD-10-CM/PCS codes, code details, or coding guidelines Before submitting a query, stop and consider the appropriateness. If there is an issue in the patient documentation that needs clarity, a physician query is necessary, and you should not be afraid of it. Queries are not the time to educate physicians about coding. ICD-10-CM/PCS codes, code details, or coding guidelines should never be included. Remember, the goal of a query is to make the record clearer, nothing more. A query should be direct in what is being asking without being leading, always provide the provider with multiple answer options and always include an "out" such as "unable to be determined."
Which of the following is an example of a physical safeguard? Locking offices and file cabinets containing PHI Identifying a privacy officer Audit controls A dual authentication for log in
Locking offices and file cabinets containing PHI Physical Safeguards are physical measures, policies, and procedures to protect a covered entity's electronic information systems and related buildings and equipment from natural and environmental hazards, and unauthorized intrusion. Some examples of physical safeguards are the following: Controlling building access with a photo-identification/swipe card system. Locking offices and file cabinets containing PHI. Turning computer screens displaying PHI away from public view. Minimizing the amount of PHI on desktops. Shredding unneeded documents containing PHI. Audit controls and effective security safeguards are part of normal operational management processes to mitigate, control, and minimize risks that can negatively impact business operations and expose sensitive data. Dual authentication is a security safeguard—combination would be a username and password
The Quality Payment Program was implemented as part of ________.
MACRA The Quality Payment Program was implemented as part of Medicare Access and Chip Reauthorization Act (MACRA). APMs are Advanced Alternative Payment Models. UCR stands for usual, customary and reasonable. HIPAA 5010 regulations govern the electronic transmission of health information between health care entities.
The federally mandated resident assessment instrument used in long-term care facilities consists of three basic components, including the new care area assessment, utilization guidelines, and the OASIS. MDS. UHDDS. DEEDS.
MDS The Minimum Data Set (MDS) is a basic component of the long-term care Resident Assessment Instrument Minimum Data Set (RAI). The wrong answers: 1) DEEDS stands for Data Elements for Emergency Department Systems and is a uniform method of collecting data in emergency departments. 2) OASIS stands for Outcome and Assessment Information Set and is an assessment method used in home health. 3) UHDDS stands for Uniform Hospital Discharge Data Set it seeks to improve the standardization and comparability of hospital discharge data and is used primarily in acute care facilities.
Which of the following is an example of an external data threat? Intern accessing celebrity medical records Unlocked workstation computer Malware and phishing attempts to steal log in credentials Power outage
Malware and phishing attempts to steal log in credentials One of the most challenging issues dealing with malware is that it only takes one seemingly authentic link to introduce a malicious cyber presence into the network. Sophisticated malware and phishing attempts can plant malicious scripts on a computer or steal login credentials that can compromise an entire system. Unlocked workstation computer and Intern accessing celebrity medical records are examples of an internal breach.
You want to review one document in your facility that will spell out the documentation requirements for patient records, designate the time frame for completion by the active medical staff, and indicate the penalties for failure to comply with these record standards. Your best resource will be quality management plan. Joint Commission accreditation manual. medical staff rules and regulations. medical staff bylaws.
Medical staff rules and regulations Although the medical staff bylaws reflect general principles and policies of the medical staff, the rules and regulations outline the details for implementing these principles, including the process and time frames for completing records, and the penalties for failure to comply. Wrong answers: 1) Quality management plan (QMP) establishes quality policies as related to organization, maintenance and improvement in the quality of care through effective treatment and improved patient satisfaction. 2) Medical staff bylaws is a document that addresses and can be considered a contract that establishes requirements of how the medical staff will perform their duties. It is a standard of performance that has been approved by the hospital's board. 3) Joint Commission accreditation manual include standards on objective evaluation process that can aid healthcare facilities measure, assess and improve performance.
As a working HIM professional, you are investigating the workforce development projections of electronic health record specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need to regularly access the website of this governmental agency. ONC OSHA CMS CDC
ONC The Office of the National Coordinator (ONC) for Health Information Technology is the federal agency charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information.
Currently, the enforcement of HIPAA Privacy and Security Rules is the responsibility of the Department of Recovery Audit Coordinators. Office of Inspector General. FBI. Office for Civil Rights.
Office for Civil Rights The Office for Civil Rights (OCR) ensures equal access to certain health and human services and protects the privacy and security of health information. The wrong answers: 1) Office of Inspector General identifies and battles waste, fraud, and abuse. 2) FBI Stands for Federal Bureau of Investigation. This agency focuses on the exposure and investigation of healthcare fraud and has jurisdiction over both federal and private insurance programs. 3) Department of Recovery Audit Coordinators primarily identify and correct Medicare improper payments
Determine which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record? database problem list progress notes initial plan
Problem list The problem list includes titles, numbers, and dates of problems and serves as a table of contents of the record.
Gerda Smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. According to her sister, Gerda has had a recent medical history taken at the public health department. The physician on call is grateful that she can access this patient information using the area's CPOE. RHIO. expert system. EDMS system.
RHIO RHIO stands for Regional Health Information Organization. With the increasing number of health care entities implementing EHR systems, the networking of electronic information between facilities has become a reality in some areas due to the establishment of regional health information organizations. The wrong answers: 1) EDMS = electronic data management system. It is used to create, capture, index, distribute, review, maintain, store, retrieve, and dispose of information. 2) CPOE stands for computerized provider order entry system. CPOE is the process used by healthcare providers to enter and send medication orders and treatment instructions electronically. 3) Expert system is a knowledge-based system
While performing routine quantitative analysis of a record, a medical record employee finds an incident report in the record. The employee brings this to the attention of her supervisor. Determine which best practice should the supervisor follow to deal with this situation? Refer this record to the Risk Manager for further review and removal of the incident report. Tell the employee to leave the report in the record. Remove the incident report and send it to the patient. Remove the incident report and have nursing personnel transfer all documentation from the report to the medical record.
Refer this record to the Risk Manager for further review and removal of the incident report. Incident reports are written accounts of unusual events that have an adverse effect on a patient, employee, or facility visitor and should never be filed with the patient's record. Incidents reports document accident and injuries. Wrong answers: Inappropriate answers would be 1) Tell the employee to leave the report in the record or ignoring the report. 2) Remove the incident report and send it to the patient. 3) Remove the incident report and have nursing personnel transfer all documentation from the report to the medical record.
The foundation for communicating all patient care goals in long-term care settings is the Uniform Hospital Discharge Data Set. cognitive assessment. interdisciplinary plan of care. legal assessment.
Uniform Hospital Discharge Data Set
You are developing a complete data dictionary for your facility. Determine which of the following resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals? Uniform Hospital Discharge Data Set Conditions of Participation Minimum Data Set Federal Register
Uniform Hospital Discharge Data Set UHDDS is the core data set for inpatient admissions and includes inpatient hospital discharges. The wrong answers: 1) The Federal Register is a daily government newspaper for publishing proposed and final rules of federal agencies. 2) The Minimum Data Set is designed for use in long-term care facilities. 3) The Conditions of Participation is the set of regulations that health care institutions must follow to receive Medicare reimbursement.
Determine which feature is a trademark of an effective PI program? an unmanageable project that is too expensive a cost-containment effort a continuous cycle of improvement projects over time a one-time cure-all for a facility's problems
a continuous cycle of improvement projects over time PI stands for Performance Improvement. An effective PI program should have a continuous cycle of improvement projects over time. Wronganswers: A PI program includes systematic activities that are organized to monitor, assess, and improve quality of care. Therefore, the followingwould not help achieve the goal of PI: 1) an unmanageable project that is too expensive 2) A one-time cure-all for a facility's problems 3) A costcontainmenteffort.
.Your hospital is required by the Joint Commission and CMS to participate in national benchmarking on specific disease entities for quality of care measurement. This required collection and reporting of disease-specific data is considered a group of sentinel events. risk assessment. an environment of care. a series of core measures.
a series of core measures. Core measures are analyzed to compare and contrast outcomes between facilities, that is, benchmarking
An effective query process supports the hospital's compliance with coding regulations. billing regulations. AHRQ regulations. billing and coding regulations only.
billing and coding regulations only *An effective query process supports the hospital's compliance with billing/coding rules and serves as an educational tool for providers, CDI professionals, and coding professionals, on the physician side. *The Agency for Healthcare Research and Quality (AHRQ) is the lead Federal agency charged with improving the safety and quality of America's health care system.
Patient data collection requirements vary according to health care setting. Determine the data element you would expect to be collected in the MDS but NOT in the UHDDS principal diagnosis. personal identification. cognitive patterns. procedures and dates.
cognitive patterns Cognitive patterns represent a data item collected more typically in long-term care settings and required in the Minimum Data Set for Long Term Care. Principal diagnosis, procedures and data, and personal identification represent items collected on Medicare inpatients according to UHDDS requirements.
Patient data collection requirements vary according to health care setting. Determine the data element you would expect to be collected in the MDS but NOT in the UHDDS
cognitive patterns. Cognitive patterns represent a data item collected more typically in long-term care settings and required in the Minimum Data Set for Long Term Care. Principal diagnosis, procedures and data, and personal identification represent items collected on Medicare inpatients according to UHDDS requirements.
The Recovery Audit Contractor (RAC) program was developed to identify and reduce improper payments for collection of overpayments. Medicaid claims. Medicare claims and collection of overpayments. Medicare claims.
collection of overpayments The RAC program is mandated to find and correct improper Medicare payments paid to health care providers participating in the Medicare reimbursement program. Wrong answers: 1) Medicare claims-Filing a claim for reimbursement purposes for services rendered for a Medicare beneficiary. 2) Medicaid claims- Filing a claim for reimbursement purposes for services rendered for a Medicaid beneficiary.
The utilization review coordinator reviews inpatient records at regular intervals to justify necessity and appropriateness of care to warrant further hospitalization. Determine which of the following utilization review activities is being performed? continued stay review admission review retrospective review preadmission
continued stay review A continued stay review documents the necessity that each day of hospitalization is required, and treatment is being provided at the appropriate level. The phrase "to warrant further hospitalization" directly indicates the review is for continued stay. Wrong answers: 1) Admission review determination of medical necessity as to whether hospitalizing is appropriate. 2) Pre-admission review refers to approval by a case manager or third-party payer representative for a person to be admitted to a hospital prior to the admittance. 3) Retrospective review the review process take place after treatment is provided.
A retrospective review as part of quality improvement activities is conducted after the patient has been discharged. admitted. cleared for surgery. released from the surgical recovery room.
discharged Admitted is the time the patient enters the hospital. This would be part of a concurrent review. Cleared for surgery would be a clinical or medical necessity review. Discharged is the point where a retrospective review would be conducted, because the treatments and care of the patient is now in the past. This is the correct answer. Released from the surgical recovery room might require a review of the procedure itself.
Determine which of the following is least likely to be identified by a retrospective quantitative analysis of a health record? discrepancy between postoperative diagnosis by the surgeon and pathology diagnosis by the pathologist X-ray report charted on the wrong record need for physician authentication of two verbal orders missing discharge summary
discrepancy between postoperative diagnosis by the surgeon and pathology diagnosis by the pathologist Discrepancy between postoperative diagnosis by the surgeon and pathology diagnosis by the pathologist represents a more in-depth review dealing with the quality of the data documented.
As the chair of a Forms Review Committee, you need to track the field name of a particular data field and the security levels applicable to that field. Determine the best source for this information glossary of health care terms. MDS. UHDDS. facility's data dictionary.
facility's data dictionary A data dictionary should include security levels for each field as well as definitions for all entities
Determine which one of the following would be an essential item captured on the physical exam. family history as related by the patient. general appearance as assessed by the physician. chief complaint. subjective review of systems.
general appearance as assessed by the physician The exam begins with the physician's objective assessment of the patient's general condition. The medical history (including chief complaint, history of present illness, past medical history, personal history, family history, and a review of systems) is provided by the patient or the most knowledgeable available source.
Determine which of the following is an example of a primary data source for health care statistics is the hospital census. accession register. MPI. disease index.
hospital census Is an official count of the total number of patients admitted to the facility by midnight. Primary data is data collected by a researcher from firsthand sources. Hospital census is an example of primary data. Wrong answers: Disease index, accession register, and MPI are examples of secondary data sources.
A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probable reasons for the fall. Determine where she would most likely find this information. incident report. nurses' notes. integrated progress notes. doctors' progress notes.
incident reports Factual summaries investigating unexpected facility events should not be treated as part of the patient's health information and therefore would not be recorded in the health record.
Using a Role-Based Access Control methodology to determine who gets access to which files within an electronic health record (EHR) means that password controls will be identified by full-time / part-time status. the workstation being used. the individual's job description. seniority (who has been there the longest).
individual's job description Role-Based Access Control to an EHR is determined by the individual's job description, identifying which records they are permitted to access and whether they can read and write or read only.
According to the HIPAA privacy rule, protected health information includes non-individuially identifiable health information in any format stored by a health care provider. only electronic individually identifiable health information. only paper individually identifiable health information. individually identifiable health information in any format stored by a health care provider or business associate.
individually identifiable health information in any format stored by a health care provider or business associate Individually identifiable health information in any format stored by a health care provider or business associate. PHI includes all individually identified health information, regardless of format. ePHI, however, includes only electronic PHI. Incorrect answers: The following are partial 1) individually identifiable health information in any format stored by a health care provider. 2) Only electronic individually identifiable health information. 3) Only paper individually identifiable health information.
As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity and to confirm that necessary documents such as X-rays or medical records are available. They must also develop and use a process for including the surgeon in the preanesthesia assessment. marking the surgical site. apprising the patient of all complications that might occur. including the primary caregiver in surgery consults.
marking the surgical site The Joint Commission requires hospitals to mark the correct surgical site and to involve the patient in the marking process to help eliminate wrong site surgeries. Wrong answers: Remember the aim of the Joint Commission National Patient Safety Goal is to ensure the correct patient gets the correct procedure thereby preventing mistakes in surgery. The following are not included in the process: The primary caregiver, surgeon involved in the preanesthesia assessment or communicating complications that might occur to the patient.
In creating a new form or computer view, the designer should be most driven by needs of the users. QIO standards. flow of data on the page or screen. medical staff bylaws.
medical staff bylaws The needs of the user are the primary concern in forms design. The wrong answers: 1) QIO standards. QIO stands for Quality Improvement Organization and is aimed at improving the quality of healthcare for all Medicare patients. 2) Flow of data on the page or screen is important as the presentation reinforces concise points but not the primary concern. 3) medical staff bylaws is a document that addresses and can be considered a contract that establishes requirements of how the medical staff will perform their duties. It is a standard of performance that has been approved by the hospital's board.
A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the history and physical is true in this situation? Completion and charting of the H&P indicates compliance with Joint Commission standards. compliance with Medicare regulations. compliance with Joint Commission standards for nonsurgical patients. noncompliance with Joint Commission standards
noncompliance with Joint Commission standards Joint Commission specifies that H&Ps must be completed within 24 hours or prior to surgery. Therefore, it does not comply with the Joint Commission regulations or Medicare regulations.
In preparation for an EHR, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is operative report. pathology report. discharge summary. recovery room record.
pathology report Although a gross description of tissue removed may be mentioned on the operative note or discharge summary, only the pathology report will contain a microscopic description. The wrong answers: 1) Operative report documents the details of a procedure or surgery. 2) Recovery room record-immediately after surgery the patient will be taken to the Recovery room where healthcare providers will monitor the patient's post-procedural care. The length of time in Recovery room is dependent on the type of procedure and anesthesia, usually recovery room time is 1 - 1 ½ hours. 3) Discharge summary is a document completed by the attending physician when the patient leaves the hospital. The goal is to communicate the patient's care plan to the post-hospital provider.
Using the SOAP style of documenting progress notes, choose the "subjective" statement from the following. sciatica unimproved with hot pack therapy adjust pain medication; begin physical therapy tomorrow patient moving about very cautiously, appears to be in pain patient states low back pain is as severe as it was on admission
patient states low back pain is as severe as it was on admission SOAP notes - SOAP stands for subjective, objective, assessment, and plan. This a documentation format containing four parts. This aim is to improve evaluations and standardize documentation. Subjective section is the section where the patient explains the complaint in their own words. This is the history section.
During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day 4 of hospitalization, there was one missed dose of insulin. Determine what type of review is this clerk performing? qualitative analysis legal review quantitative analysis utilization review
qualitative analysis The qualitative analysis may involve checking documentation consistency, such as comparing a patient's pharmacy drug profile with the medication administration record.
A powerful communication tool used to clarify documentation in a health record and achieve accurate code assignment is called a halo effect. query. POA. SOR.
query *A query can be a powerful communication tool used to clarify documentation in a health record and achieve accurate code assignment. Querying has become a common communication and educational tool for clinical documentation improvement (now integrity, or CDI) and coding departments. An effective query process aids the hospital's compliance with billing/coding rules and serves as an educational tool for providers, CDI professionals, and coding professionals, on the physician side. Present on Admission (POA) is defined as being present at the time the order for inpatient admission occurs. Halo effect is a form of bias that should be avoided during the performance appraisal process. Example: Supervisor Sally Shields may assign high performance ratings to an employee based solely on the fact that she likes the employee. Source Oriented Record (SOR) Traditional patient record format that maintains reports according to source of the document.
Accreditation by Joint Commission is a voluntary activity for a facility, and it is considered unnecessary by most health care facilities. conducted in each facility annually. required for reimbursement of certain patient groups. required for state licensure in all states.
required for reimbursement of certain patient groups.
In your acute care facility it has become critical that up-to-date information regarding patients who are transferred to the oncology patient care unit be immediately sent to an outpatient scheduling system to facilitate outpatient appointments. This transfer of service can be obtained most readily from the indicator monitoring program. generic screens used by record abstractors. the disease index. the R-ADT system.
the R-ADT system. R-ADT stands for Registration, Admission, Discharge, Transfer Systems. The R-ADT system tracks when patients are admitted to the hospital or outpatient services and opens an account.
Determine the key data item you would expect to find recorded on an ER record but would probably NOT see in an acute care record physical findings. lab and diagnostic test results. time and means of arrival. instructions for follow-up care.
time and means of arrival All choices are required items in BOTH acute and ER records except time and means of arrival, which is a required item only for ER documentation.
The purpose of the NCCI medically unlikely edits is to examine standard medical and surgical practices. designed to link reimbursement to quality care. to prevent inaccurate payments when services are reported with incorrect units of service. to identify services that should not be performed on the same patient on the same day of service.
to prevent inaccurate payments when services are reported with incorrect units of service
The master patient index must, at a minimum, include sufficient information to list all physicians who have ever treated the patient. uniquely identify the patient. justify the patient's hospital bill. summarize the patient's medical history.
uniquely identify the patient At a minimum master patient index (MPI) must hold unique identification that may include a unique medical record number for each patient(e.g., social security number), name, date of birth, sex, address, a photograph, or/and other personal immutable properties. Wrong answers: 1)The MPI also contains information regarding all patients seen at the facility. The MPI is never destroyed. It is retained permanently. 2) The MPI does not justify the patient's hospital bill nor does it 3) summarize the patient's medical history.
In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the commission's national patient safety goals, the focus has shifted to the
use of prohibited or "dangerous" abbreviations As part of its National Patient Safety Goals initiative, the Joint Commission required hospitals to prohibit abbreviations that have caused confusion or problems in their handwritten form, such as "U" for unit, which can be mistaken for "O". Spelling out the word "unit" is preferred. The wrong answers: Remember, all fields of healthcare use abbreviations from surgical department to discharge. The Joint Commission requires the use of standardized abbreviation. Keep in mind Specialty-specific abbreviations lack consistency and those working outside the specialty field may not be able to interpret them accurately.