The health care providers at your hospital do a very thorough job of periodic open record review
to ensure the completeness of record documentation. A qualitative review of surgical records
would likely include checking for documentation regarding
A. the presence or absence of such items as preoperative and postoperative diagnosis, description
of findings, and specimens removed.
B. whether a postoperative infection occurred and how it was treated.
C. the quality of follow-up care.
D. whether the severity of illness and/or intensity of service warranted acute level care.
A "Whether a postoperative infection occurred and how it was treated" represents an
appropriate job for the infection control officer. "The quality of follow-up care" represents the
clinical care evaluation process, rather than the review of quality documentation. "Whether
the severity of illness and/or intensity of service warranted acute level care" is a function of
the utilization review program.
You might also like to view...
Medical policies, procedures, and practices that a system medical director has established in advance of a call are called:
A) automated medical direction. B) off-line medical oversight. C) remote medical direction. D) on-line medical direction.
Iron-deficiency anemia can occur from what three mechanisms?
a. Impaired iron absorption, blood loss, inadequate iron intake b. ALAS deficiency, blood loss, decreased transferrin c. Mutation of HFE gene, decreased transferrin, increased hepcidin d. Inadequate iron intake, impaired iron absorption, decreased hepcidin
Why may a paper record need to be retrieved from the file room?
A. Incomplete documentation has been submitted. B. It is needed for risk management review. C. The patient is readmitted. D. All of these
The first step in composing a letter is to:
A) compose a rough draft B) select the type of font and size C) determine what information needs to be included D) select the style for the letter