Week 6 Flashcards
(37 cards)
About patient medical information, a patient’s health records are considered ____________
Legal Documents
What Act states that a patient can request that her images be sent to another mammography service?
MQSA Mammography Quality Standards Act
It is important for the professional imaging technologist to thoroughly understand his or her responsibilities regarding health information confidentiality. Particular considerations include:
- All examination results are released by physicians only
- The testimonial statement must be signed
- All staff have the same standards for maintaining confidentiality
In the event a correction is needed in a paper document in a patient health record, what needs to be done to the entry?
to draw a single line through the error, write “ERROR,” and then record the correct information.
What items need to be considered as part of a medical imaging quality assurance program?
- Medication errors
- Thermal injuries occurring in MRI
- Timespan available to schedule mammograms
- Radiology department rate of repeat
- Patient satisfaction results
An effective hospital quality improvement program includes _________
the operations and effectiveness of the hospital’s medical staff
What would be the purpose of a radiology department’s quality assurance committee?
Promote continuous improvement
The ICD-10-CM codes for radiologic procedures using CPT coding nomenclature range from?
70010-79999
To maximize the full reimbursement for a diagnostic study performed in medical imaging, what has to be included?
- The correct CPT code using the ICD-10-CM nomenclature.
- Any changes to radiology examinations must be communicated with the hospital chargemaster so that the correct CPT-4 code is assigned.
- The correct DRG must be attached to inpatient studies performed.
In 2007, the government upgraded the DRG system of reimbursement and introduced the MS-DRG system. This upgrade is designed to take into account?
The upgrade was designed to take into account the severity of illness, particularly by distinguishing between patients with and without complications and comorbidities.
A major distinction between DRGs and APCs is that APCs are ___________
used for the reimbursement of outpatient and ancillary procedures
When entering data into a patient chart, it is important to remember that any data entered must be ___________
legible and in ink
A key function performed by a patient’s health information record is to?
Facilitate communication with everybody.
*Before a diagnostic study can be initiated, what three things must be done?
- a formal, documented examination request is entered into the institution’s information system
- the requesting physician must be identified on the request
- and reasons for the examination must be on the request.
If a patient gets injured while under your care…
the incident report must be part of the hospital’s risk management documentation
Health records for inpatients should contain what information?
Identify the patient
Reports of diagnosis or therapeutic data
Physical examination data
All informed consent documents
Medical history
Who enters health information into a patient’s medical record (chart)?
All departments that take part in the care of a patient must document that care in the health record.
Standards have been established for the maintenance of completed medical records by _____________
The Joint Commission
What is Coding?
Critically important to the complete and timely reimbursement of medical costs provided by the government (Medicare/Medicaid) and third-party payers
The health information department performs what supportive functions?
Support health services research.
Administrative activities of the organization
Support for medical education activities
Patient billing and accounting
Quality management
What department is responsible for the maintenance, retrieval, and storage of health information?
Health Information Management department
What are the characteristics of a patient health record?
Single record on a single patient
Maintained in paper or electronic media or both
Promotes communication among providers and continuity of care
Define veracity
Being truthful
Define fidelity
Procuring an image that faithfully produces the patient’s images
Being faithful. Performing acts that observe covenants or promises.
