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

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?  

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

An HIM Department Budget Report for May shows a payroll budget of $25,000 and an actual payroll expense of $22,345. The percentage of budget variance for the month is:

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?”

Mary is 6 weeks postmastectomy for carcinoma of the breast. She is admitted for chemotherapy. What is the correct sequencing of the codes?

In reviewing the policies on release of information in respect to the privacy rules, you note that it is still acceptable to allow release of protected health information without patient permission to

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:

EHR Continued Nursing 2/11 1200 Neuro/Cognitive: A/Ox3. Speech even and clear. Pupils 3 mm PERRLA. Denies any visual changes or disturbances. DTRs 4+, +clonus-one beat. Epidural in place. Client able to move legs slightly. No sensation up to hips. Respiratory: Lung sounds clear bilaterally, breathing unlabored. Cardiovascular: Apical pulse 76 beats per minute, regular, S1 & S2 sounds present. Peripheral Vascular: Skin pink, warm, and dry. +3 pitting edema in left and right lower extremities. Gastrointestinal: Abdomen distended consistent with pregnancy. Bowel sounds present. Last bowel movement two days ago. Genitourinary: Indwelling urinary catheter in place, draining freely. Urine dark yellow, clear. Pain: Client denies feeling any pain, only pressure from contractions. 2/11 1200 Nursing Note: Contractions palpated, moderate intensity, occurring every 2-2 ½ minutes lasting 80-100 sec. Fetal heart rate tracings indicate late decelerations. Sterile vaginal exam performed. Client is 7 cm dilated, 80% effaced, at 0 station. Client’s sister at the bedside for support. intake and output Date Intake Source & Amount Output Source & Amount 2/11 1100 IV Fluids: 125 mLIce chips: 240 mL Urine: 40mL 2/11 1200 IV Fluids: 125 mLIce chips: 240 mL Urine: 35 mL   Before answering this question, review the client’s health information in the EHR. The nurse will implement the following interventions based on the fetal heart rate tracings. Select all that apply.    

Report: Hi, this is Dr. King calling. I am sending in Lelna Mengistu, a 37-year-old G4P2A1L2 at 32+1 weeksgestation. She is experiencing vaginal bleeding and says she doesn’t think she is having anycontractions. She is O+, hep-, and rubella immune. You will find all relevant prenatal labs andinformation in her EHR, and I will put in some preliminary prescriptions now. I’m downstairs in the oncall room. Call me once she has arrived and is on the fetal monitor.  EHR: NURSING ASSESSMENT & NOTES 12/12 0230 Nursing Note: Client arrived to triage by herself. She got up to go to the bathroom and saw that she bled through her underwear and pajama bottoms.  She did not notice any blood in the toilet but there was bright red blood on the toilet paper when she wiped. She placed a pad on and immediately called Dr. King who instructed her to come in. She states she was told her placenta is lying low but it would “probably resolve” before delivery, and she is scheduled for an ultrasound later this week. Husband at home trying to find a babysitter so he can join her, as they have no family nearby. She denies feeling any contractions. Dr. King notified of client’s arrival. PROVIDER PRESCRIPTIONS & NOTES 12/12 0250 Prescriptions: Admit to labor and delivery for observation Continuous external fetal and contraction monitoring Vaginal exam Complete blood count Place IV saline lock Type and screen COAG Panel: PT, PTT, Fibrinogen Transvaginal ultrasound Complete bedrest Place indwelling urinary catheter Other 12/12 0230 Client Information:Obstetric History: G4T2P0A1L2; LMP 5/01 EDD 2/5 Transvaginal ultrasound at 18 weeks identified a low-lying placenta Scheduled for repeat ultrasound at 32 weeks   Medical History: Myomectomy Spontaneous vaginal delivery x2 Elective abortion   Before answering this question, review the client’s health information in the EHR. Identify symptoms or risk factors that are related to placenta previa, placental abruption, or both. Select the correct answer. Question Placenta previa   Placental abruption Both Uterine contractions [AnswerA] History of abortion  [AnswerB]  History of smoking [AnswerC] Vaginal bleeding [AnswerD] Advanced maternal age [AnswerE] Abnormal placental location[AnswerF] Increase in fundal height disproportionate to gestational weeks [AnswerG] Recent blunt external abdominal trauma [AnswerH] Abdominal tenderness/pain [AnswerI]