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</p> Signup and view all the answers

    Which accreditation organization provides deemed status for healthcare organizations?

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

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

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

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

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

    What do documentation standards in healthcare dictate?

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

    What do documentation standards encompass?

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

    When should health record entries be documented?

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

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

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

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

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

    What does a Physician Office Record mainly focus on?

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

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