Which of the following is NOT a function of a hospital health information management department?
coding of diagnoses and operative procedures and diagnosis-related group assigning
documenting relevant patient information in the medical record
quality management and performance improvement activities
appropriate release of medical information
documenting relevant patient information in the medical record
The perspective payment system is a payment system based on which of the following?
the diagnosis-related group (DRG) or the ambulatory patient classification (APC)
the coding system based on the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM)
the current Procedural Terminology (CPT) coding system
the resource based relative value system (RBRVS)
the diagnosis-related group (DRG) or the ambulatory patient classification (APC)
Which of the following ia an example of an organization that accredits hospitals and other health care institutions in the United States?
American Hospital Association
American Medical Association
The Joint Commission
American College of Radiology
The Joint Commission
The chielf complaint, included in a patient's history, is a statement made by the:
patient
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) legislation affects radiology and other hospital departments by its focus on:
patient record confidentiality
Which of the following is not required to be in a patient's health record?
medical history
radiology reports
patient's telephone number
physical examination report
patient's telephone number
Criteria used in performance improvement activities must be all of the following EXCEPT:
clinically valid
diagnosis or procedure oriented
generally acceptable to department staffs
written
clinically valid
Assessment of problems in performance improvement activities must be:
ongoing
In making a correction to an entry in the paper health record, the documenter should:
line out the error, authenticate, and insert correct information
The organization (chart order, forms) of a hospital patient record is determined by:
the hospital's own preference