Exam 25: Health Records and Health Information Management

You are asked to testify in a court case involving a mammographic biopsy with which you were involved as a mammographer.During testimony,a question is raised regarding whether the biopsy was done successfully.You remember clearly that it was and state that.In the patient's health record,there is no written documentation of the biopsy being done.As far as the court is concerned,

A typical health information management department

A major distinction between DRGs and APCs is that

Health records for inpatients should contain what information? 1)Patient identification data 2)Number of patient visitors during the stay 3)Reports of any diagnostic or therapeutic studies 4)Physical examination data 5)Number of times the nurse call light is activated for nursing care 6)All informed consent documents 7)Medical history,including the chief complaint

Standards have been established for the maintenance of complete medical records by

All of the following would be characteristics of a patient health record EXCEPT it

To maximize the full reimbursement for a diagnostic study performed in medical imaging,

The ICD-10-CM codes for radiologic procedures using CPT coding nomenclature range from

It is important for the professional imaging technologist to thoroughly understand his or her responsibilities with regard to health information confidentiality.Particularly important considerations include

An effective hospital quality improvement program

You have been asked to participate on the radiology department's quality assurance committee.The purpose of this committee would most likely be to

The health information department performs which of the following supportive functions?

As a radiographer working in a busy department,you have received an examination request for an interventional venous line placement for an inpatient.The referring physician is very upset about any delay with his patient.In reviewing the request,you notice that there is no indication as to why this examination is being done.How would you proceed with this situation?

According to the Mammography Quality Standards Act,

Entering health information into a patient's medical record (charting)is completed by

When entering information into a patient health record,it is important to remember that

A key function performed by a patient's health information record is to

As a professional imaging team member,it is important to remember that

In the event a correction is needed in a paper document in a patient health record,

In 2007,the government upgraded the DRG system of reimbursement and introduced the MS-DRG system.This upgrade is designed to take into account