The Joint Commission requires that medical record review is performed to evaluate adequacy, accuracy, completeness, and quality of documentation

As HIM Director, you have been asked to revise the record retention schedule for records maintained by the facility. The best resource to revise the retention schedule is:

Physician documentation in an inpatient operative report indicates ‘removal of the gallbladder’. The ICD-10-PCS root operation is:

An HIM director wants to improve departmental productivity. Which strategy would likely have the greatest impact?

In reviewing the discharges from yesterday, you notice that one of the records has no discharge order, indicating that the patient may have left AMA. In this situation, you would expect to see the circumstances of the leave

This can be described as a  process designed to identify, evaluate and resolve actual and possible sources of liability for an organization.

Based on documentation requirements for patient records, what document might contain this documentation? With the patient in the supine position, the abdomen was prepped and draped for the procedure. A small incision was made just below the umbilicus and the laparoscope inserted.

Which of the following health record formats consists of four main components – database, problem list, initial plan and progress notes? The progress notes in this type of record are usually recorded in the SOAP format.

Modifier 50 is used with a CPT code when the exact same service/code is reported for each of the bilateral anatomical sites.  Modifier 50 would be required in which of the following cases?

An internist is seeing a patient for the first time in the office. He assigns an evaluation and management code for a new patient. What documentation must be used to properly assign the evaluation and management code?