A 6-month-old infant, born prematurely, presents for his monthly injection for RSV. The nurse documents Synagis 40 mg, IM. Which of the following code sets is correct for reporting this office visit? Show 90378 Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) 96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components; a problem focused history; a problem focused exam; straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problems and the patient's and/or family's needs. Usually, the presenting problem(s) are self-limited or minor. J1459 Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g. liquid), 500 mg 99212, 90378, 96372 Recommended textbook solutions
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Terms in this set (35)Which of the following best describes the most important function of the health record? storing patient care documentation Which of the following HIM tasks is eliminated by the electronic health record system? assembly Reviewing the health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of what type of analysis? quantitative The coding of clinical diagnoses and healthcare procedures and services after the patient is discharged is what type of review? retrospective Which filing system is best suited for a small healthcare facility such as a one-physician practice? alphabetical filing system The release of information function requires the HIM professional to: Disclose patient identifiable information to a third party In which of the following systems does an individual receive a unique numerical identifier at the time of first encounter with a healthcare facility and maintain that identifier for all subsequent encounters? Unit numbering system clinical professionals who provide direct patient care are _______ users of health records primary user A record not completed within the time frame specified in the medical staff rules and regulations is called a ____________. delinquent record Which of the following should be taken into consideration when designing a health record form? including original and revised dates File the record alphabetically by the last name, followed by the first name, and then the middle initial. alphabetical filing Which of the following is a micrographic method of storing health records in which each document page is placed sequentially on a long strip? microfilm roll what filing method is considered the most efficient? terminal digit filing which of the following indexes is key to locating a health record? master patient index 29. An addendum to the health record should be dated _____. the day the addendum was created which of the following elements is typically found in the paper health record patient identification why should the copy and paste function not be used in the electronic health record? the content may contain outdated information what committee oversees the development and approval of new forms for the health record? health information management committee what is the software that is used for voice recognition known as natural language processing Critique this statement: Version control is not an issue in the EHR. There are issues related to versions of documents, such as there must be a flag to indicate a previous version. Dr. Smith wants to use a lot of free text in his EHR. What should be your response? Dr. Smith, we recommend that you use little, if any, free text in the EHR. Which of the following is a secondary purpose of the health record? support for research Which of the following is a disadvantage of alphabetic filing? Uneven expansion in file shelves or cabinets Which of the following is a request from a clinical area to charge out a health record? requisition "The number of patients discharged has increased 175% over the past year." is an example of: information What would be the linear filing inch capacity for a shelving unit with 6 shelves, each measuring 36 inches? 216 inches A quantitative review of the health record for missing reports and signatures that occurs when the patient is in the hospital is referred to as a _______ review. concurrent In which department or unit does the health record typically begin? patient registration The term used for health record moved to an inactive file area because they have not been at the healthcare facility for a predefined period of time is: Purged Our transcription is performed by a company outside of our organization. What is this called? Outsourcing Calculate the number of shelving units required for 35,000 linear filing inches of records if the shelving unit has 7 shelves and is 36 inches wide 139 Which of the following is an argument against the use of the copy and paste function in the EHR? inability to identify the author Which of the following assists in locating misfiles in the paper-based filing systems? color coding Which one of the following are included in a list of institutional users of the health record? blue cross blue shield The patient registration department assists the HIM department in what way? assigning the health record number Students also viewedA&P Chapter 3 Quiz35 terms ecshannonPlus Normal Language Development Exam 330 terms IncredibleTrinRose blaw unit 275 terms makaylatheriotttPlus Unit 517 terms blavin8 Other sets by this creatorFundamentals of Law: Chapters 8 & 951 terms Emi_Josefina Chapter 10 Test Human Disease & Condition29 terms Emi_Josefina Chapter 12105 terms Emi_Josefina Health Information: Information Systems238 terms Emi_Josefina Recommended textbook solutions
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Which of the following elements should be included in a medical record?It includes informationally typically found in paper charts as well as vital signs, diagnoses, medical history, immunization dates, progress notes, lab data, imaging reports, and allergies. Other information such as demographics and insurance information may also be contained within these records.
Which of the following best describes the most important functions of the health record?Intro Final Exam. What is a health record used for quizlet?The health record is known by different names in different healthcare settings. However, no matter what term is used, the primary function of the health record is to document and support patient care services.
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Which of the following should be taken into consideration when designing a health record form quizlet?
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