Podcast
Questions and Answers
What is one of the purposes of the health record assessment?
What is one of the purposes of the health record assessment?
- To facilitate reimbursement decisions
- To compare objective and subjective assessment data (correct)
- To conduct medical record audits for quality assurance
- To provide a legal document for court use
How does the patient record serve the purpose of quality assurance?
How does the patient record serve the purpose of quality assurance?
- By allowing comparison of objective and subjective assessment data
- By facilitating reimbursement decisions
- By enabling medical record audits to determine standards of care (correct)
- By providing a legal document for court use
What is a significant aspect of the patient record with regards to reimbursement?
What is a significant aspect of the patient record with regards to reimbursement?
- Providing the basis for decisions regarding care and subsequent reimbursement (correct)
- Facilitating medical research
- Allowing comparison of assessment data
- Serving as a legal document for court use
How does accurate documentation in patient records contribute to research?
How does accurate documentation in patient records contribute to research?
What is the primary purpose of maintaining confidentiality in nursing documentation?
What is the primary purpose of maintaining confidentiality in nursing documentation?
Why should students de-identify any patient information in written assignments?
Why should students de-identify any patient information in written assignments?
What is the main guideline for nursing documentation to maintain accuracy?
What is the main guideline for nursing documentation to maintain accuracy?
Why should direct quotes of patient statements be used in nursing documentation?
Why should direct quotes of patient statements be used in nursing documentation?
What is the significance of documenting information chronologically?
What is the significance of documenting information chronologically?
Why should only commonly accepted and approved abbreviations be used in nursing documentation?
Why should only commonly accepted and approved abbreviations be used in nursing documentation?
Why is the standardized vocabulary important in the electronic health record?
Why is the standardized vocabulary important in the electronic health record?
What is the goal of the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act?
What is the goal of the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act?
What do clinical surveillance tools do in relation to electronic health record data?
What do clinical surveillance tools do in relation to electronic health record data?
What does the Universal Computer-Based Patient Record aim to achieve?
What does the Universal Computer-Based Patient Record aim to achieve?
