Healthcare and Pathology Documentation Quiz

Pathology Report

• This form contains a microscopic description of excised tissue.
• It is a key document in pathology and diagnosis.

Patient Data Collection Requirements

• Requirements differ across healthcare settings.
• Specific data elements vary based on the setting.
• Data elements collected will depend on the type of data system, such as MDS vs UHDDS

Data Security in Health Information Systems

• Strong data security is crucial.
• Implementing strong authentication systems and access controls are essential.

Tumor Registry Accession Register

• The prefix "99" in "99-0001" likely represents a specific registry category or type.
• The full accession number likely provides more context, like a unique identifier for the record.

Patient Fall Report

• A comprehensive fall report includes witness accounts and potential causes of a patient fall.
• The report will likely be located in the patient’s incident or accident report.

Ambulatory Care Documentation

• Ambulatory care providers rely more heavily on documentation beyond the immediate patient encounter.
• Ambulatory records often provide critical context for continuous care.

Auto-Authentication of Health Records

• Automatic record entry authentication is not recommended by the Joint Commission.
• The primary concern is the potential for errors due to the lack of verifying a physician's input.

Obstetrical Patient Record Review

• The best source for menstrual history, pregnancy details, and living children is in the obstetric patient’s medical history review.
• This is likely located within the patient’s prenatal history.

Concurrent Record Review

• If a physician wishes to provide an updated H&P for a prior exam, it would be required to reference the prior record.
• The original notes are preferred.

Cancer Case Identification

• Identify reportable cancer cases using the facility's cancer registry.
• This will contain past records of cancer cases reported and will be a valuable resource for your research.

Test your knowledge on key documentation in healthcare, including pathology reports, patient data collection requirements, and data security measures. Explore the intricacies of fall reports and tumor registry accession numbers as part of healthcare documentation. Ideal for students in healthcare and pathology courses.