AHIMA Documentation Standards Ch. 4
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Questions and Answers

What is the primary purpose of medical staff bylaws?

  • To prevent fraud and abuse
  • To establish documentation standards
  • To govern the practice of medical staff members (correct)
  • To ensure appropriate reimbursement

Who approves the medical staff bylaws?

  • The healthcare organization's board of directors
  • The state regulatory agency
  • The medical staff executive committee
  • Both a and b (correct)

What is the purpose of medical staff privileges?

  • To enforce quality of care
  • To specify the services and procedures a medical staff member is qualified to perform (correct)
  • To prevent fraud and abuse
  • To ensure appropriate reimbursement

Which of the following is NOT a requirement for accreditation of a healthcare organization?

<p>Compliance with medical staff bylaws (B)</p> Signup and view all the answers

Which accreditation organization provides deemed status for healthcare organizations?

<p>The Joint Commission (D)</p> Signup and view all the answers

Which of the following healthcare organizations can the Joint Commission accredit?

<p>Hospitals, ambulatory healthcare, and behavioral health (C)</p> Signup and view all the answers

What is the purpose of state statutes related to documentation requirements?

<p>To define the legal health record (A)</p> Signup and view all the answers

What is the primary purpose of the legal health record?

<p>To respond to legally permissible requests for patient information (D)</p> Signup and view all the answers

Who should be authorized to enter documentation in the health record?

<p>Only the authorized individuals specified in the organization's policies (D)</p> Signup and view all the answers

What is the primary benefit of accreditation for a healthcare organization?

<p>Enhances the organization's reputation in the eyes of patients (B)</p> Signup and view all the answers

What is the purpose of healthcare documentation according to the text?

<p>To communicate among caregivers (D)</p> Signup and view all the answers

What is an impact of poor documentation as mentioned in the text?

<p>Poor outcomes (C)</p> Signup and view all the answers

What do documentation standards in healthcare dictate?

<p>How healthcare providers should document treatment and services (D)</p> Signup and view all the answers

What do documentation standards encompass?

<p>Principles, codes, beliefs, guidelines, and regulations that guide healthcare documentation (D)</p> Signup and view all the answers

What guides how healthcare providers should document the treatment and services within the health record?

<p>Clear and specific documentation standards (D)</p> Signup and view all the answers

What should organizational policy or medical staff rules specify?

<p>Who may receive and transcribe verbal physician’s orders (A)</p> Signup and view all the answers

When should health record entries be documented?

<p>At the time the services they describe are rendered (D)</p> Signup and view all the answers

What should be used in the health record according to AHIMA guidelines?

<p>Only approved abbreviations and symbols (B)</p> Signup and view all the answers

What type of entries should be in a health record according to CMS requirements?

<p>Legible, complete, dated, timed, and authenticated (B)</p> Signup and view all the answers

What controls are required to prevent changes to authenticated health record entries?

<p>Controls to prevent any changes from being made (B)</p> Signup and view all the answers

What are the two types of health record information based on setting?

<p>Clinical and administrative data (B)</p> Signup and view all the answers

What must be documented in an Obstetric and Newborn Health Record?

<p>Labor and delivery information. (B)</p> Signup and view all the answers

What does a Physician Office Record mainly focus on?

<p>Preventive care. (B)</p> Signup and view all the answers

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