Students are not to be substituted for paid staff during any practicum assignment.  They may be permitted to perform procedures or duties under careful _____.

A patient’s husband slipped and fell in your HIM reception area and now he is suing the facility. You have to prepare detailed written answers to a long list of questions and send them to your hospital attorney. You will spend the afternoon working on

Two coders have found the same abbreviation (CO) in two records.  One abbreviation means carbon monoxide in a patient with respiratory complaints.  The other means cardiac output in a heart patient’s record.  This indicates a problem with which data quality characteristic in these records?  

The difference between an Institutional Review Board (IRB) and a hospital’s Ethics Committee is that

You are providing an educational session to new hires at your hospital. You tell the new employees that hospital records may be used as evidence in court even though hearsay laws bar the use of most evidence that does not represent personal knowledge of the witness. That is because the hospital record

The census taken at midnight on August 1 showed 99 patients remaining in the hospital. On August 2, four patients were admitted, there was one fetal death, one DOA, and seven patients were discharged. One of these patients was admitted in the morning and remained only 8 hours. How many inpatient service days were rendered on August 2?

Where would you expect to find the following documentation in the health record: “BUN 14, Creatinine 0.9, H&H 8.8 and 25.4?”

Parker has type 1 diabetes with hypertension that is currently controlled with medication. Parker was admitted through the ED for an emergency appendectomy. Following surgery, the patient developed an infection at the wound site that was treated with antibiotics. Parker’s principal diagnosis is the

The federally mandated resident assessment instrument used in long-term care facilities consists of three basic components, including the new care area assessment, utilization guidelines, and the:

Sunset Beach Clinic allows patients to communicate by e-mail to ask questions regarding their treatment and request appointment changes. E-mails and text messages are: