WGU- Classification Systems - C808 Test
Questions & Answers Verified 100% Correct
Review of Systems - ANSWER -Systematic inventory designed to uncover current
or past subjective symptoms that includes the following types of data:
* General: Usual weight, recent weight changes, fever, weakness, fatigue
* Skin: Rashes, eruptions, dryness, cyanosis, jaundice; changes in skin, hair, or
nails
* Head: Headache (duration, severity, character, location)
* Eyes: Glasses or contact lenses, last eye examination, glaucoma, cataracts,
eyestrain, pain, diplopia, redness, lacrimation, inflammation, blurring
* Ears: Hearing, discharge, tinnitus, dizziness, pain
* Nose: Head colds, epistaxis, discharges, obstruction, postnasal drip, sinus pain
* Mouth and throat: Condition of teeth and gums, last dental examination,
soreness, redness, hoarseness, difficulty in swallowing
* Respiratory System: Chest pain, wheezing, cough, dyspnea, sputum (color and
quantity), hemoptysis, asthma, bronchitis, emphysema, pneumonia, tuberculosis,
pleurisy, last chest x-ray
*Neurological System: Fainting, blackouts, seizures, paralysis, tingling, tremors,
memory loss
* Musculoskeletal System: Joint pain or stiffness, arthritis, gout backache, muscle
pain, cramps, swelling, redness, limitation in motor activity
*Cardiovascular System: Chest pain, rheumatic fever, tachycardia, palpitation,
high blood pressure, edema, vertigo, faintness, varicose veins, thrombophlebitis
*Gastrointestinal System: appetite, thirst, nausea, vomiting, hematemesis, rectal
bleeding, change in bowel habits, diarrhea, constipation, indigestion, food
intolerance, flatus, hemorrhoids, jaundice
*Urinary System: Frequent or painful urination, nocturia, pyuria, hematuria,
incontinence, urinary infections
*Genitoreproductive System: Male - venereal disease, sores, discharge from penis,
hernias, testicular pain, or masses; Female - age at menarche, frequency and
duration of menstruation, dysmenorrhea
, Discharge Summary - ANSWER -Also called the clinical resume, provides details
about the patient's stay while in the facility and is the foundation for future
treatment. It is prepared when the patient is discharged or transferred to another
facility or when the patient expires. It states the reason for hospitalization and
gives a brief history explaining why they needed to be hospitalized. Not typically
required for patients who have been in the hospital for 48 hours or less.
Quantitative Analysis - ANSWER -Often called discharge analysis is a review of
the health record for completeness and accuracy. Generally conducted
retrospectively, after the patient's discharge from the facility or at the conclusion of
treatment.
Concurrent Analysis/Review - ANSWER -Concurrent analysis means that the
record is analyzed during the patient's stay in the healthcare facility.
Authentication - ANSWER -To prove authorship and can be done in several ways.
Signatures handwritten in ink are the most common method for signing paper-
based health records. The joint commission allows rubber-stamp facsimile
signatures when there is a statement verifying that the physician is the only one
who will use the stamp and will maintain control of it. CMS specifically forbids
the use of rubber stamps as an authentication method. For electronic records an
electronic signature can be used.
Electronic Signature - ANSWER -An electronic signature or e-signature is "any
electronic process signifying an approval or terms and/or documentation presented
in electronic format." Methods of electronically signing documentation include a
digital signature, a digitized image of a signature, a bio-metric identifier such as a
fingerprint or retinal scan, or a code or password.
Qualitative Analysis - ANSWER -In qualitative analysis, HIM personnel carefully
review the quality and adequacy of record documentation and ensure that it is an
accordance with the policies, rules, and regulations established by the facility; the
standards of licensing and accreditity bodies; and government requirements.
, Open-record review - ANSWER -When qualitative analysis is done while the
patient is in the facility or under active treatment, it is called open-record review,
ongoing records review, point-of-care review, or continuous record review.
Closed-record review - ANSWER -The qualitative review is done retrospectively
following discharged or termination of treatment.
Delinquent Health Records - ANSWER -Those records that are not completed
within the specified time frame, for example, within 14 days of discharge. The
definition of a delinquent chart varies according to the facility, but most facilities
require that records be completed within 30 days of discharge as mandated by
CMS regulations and Joint Commission standards. The Joint Commission specifies
that the number of delinquent records cannot exceed 50 percent of the average
number of discharges.
Clinical Documentation Improvement - ANSWER -A process to facilitate the
accurate representation of a patient's clinical status in the patient health record that
is then transformed into coded data.
Diagnosis and procedure codes - ANSWER -* Medicare severity diagnosis-related
groups (ms-drg)
* Value-based purchasing (vbp)
* Quality of care measures including inpatient quality reporting (iqr)
* Severity of illness (soi)
* Expected risk of mortality (rom)
* Present on admission (poa) or hospital-acquired condition (hac) reporting
*Patient saftey measures
* Utilization of resource measures such as case-mix and medical necessity
* Protection from liability
* Public health monitoring
CDI Program - ANSWER -Function is to initiate concurrent and, as appropriate,
retrospective reviews of health records fro conflicting, incomplete, or nonspecific
provider documentation.
Questions & Answers Verified 100% Correct
Review of Systems - ANSWER -Systematic inventory designed to uncover current
or past subjective symptoms that includes the following types of data:
* General: Usual weight, recent weight changes, fever, weakness, fatigue
* Skin: Rashes, eruptions, dryness, cyanosis, jaundice; changes in skin, hair, or
nails
* Head: Headache (duration, severity, character, location)
* Eyes: Glasses or contact lenses, last eye examination, glaucoma, cataracts,
eyestrain, pain, diplopia, redness, lacrimation, inflammation, blurring
* Ears: Hearing, discharge, tinnitus, dizziness, pain
* Nose: Head colds, epistaxis, discharges, obstruction, postnasal drip, sinus pain
* Mouth and throat: Condition of teeth and gums, last dental examination,
soreness, redness, hoarseness, difficulty in swallowing
* Respiratory System: Chest pain, wheezing, cough, dyspnea, sputum (color and
quantity), hemoptysis, asthma, bronchitis, emphysema, pneumonia, tuberculosis,
pleurisy, last chest x-ray
*Neurological System: Fainting, blackouts, seizures, paralysis, tingling, tremors,
memory loss
* Musculoskeletal System: Joint pain or stiffness, arthritis, gout backache, muscle
pain, cramps, swelling, redness, limitation in motor activity
*Cardiovascular System: Chest pain, rheumatic fever, tachycardia, palpitation,
high blood pressure, edema, vertigo, faintness, varicose veins, thrombophlebitis
*Gastrointestinal System: appetite, thirst, nausea, vomiting, hematemesis, rectal
bleeding, change in bowel habits, diarrhea, constipation, indigestion, food
intolerance, flatus, hemorrhoids, jaundice
*Urinary System: Frequent or painful urination, nocturia, pyuria, hematuria,
incontinence, urinary infections
*Genitoreproductive System: Male - venereal disease, sores, discharge from penis,
hernias, testicular pain, or masses; Female - age at menarche, frequency and
duration of menstruation, dysmenorrhea
, Discharge Summary - ANSWER -Also called the clinical resume, provides details
about the patient's stay while in the facility and is the foundation for future
treatment. It is prepared when the patient is discharged or transferred to another
facility or when the patient expires. It states the reason for hospitalization and
gives a brief history explaining why they needed to be hospitalized. Not typically
required for patients who have been in the hospital for 48 hours or less.
Quantitative Analysis - ANSWER -Often called discharge analysis is a review of
the health record for completeness and accuracy. Generally conducted
retrospectively, after the patient's discharge from the facility or at the conclusion of
treatment.
Concurrent Analysis/Review - ANSWER -Concurrent analysis means that the
record is analyzed during the patient's stay in the healthcare facility.
Authentication - ANSWER -To prove authorship and can be done in several ways.
Signatures handwritten in ink are the most common method for signing paper-
based health records. The joint commission allows rubber-stamp facsimile
signatures when there is a statement verifying that the physician is the only one
who will use the stamp and will maintain control of it. CMS specifically forbids
the use of rubber stamps as an authentication method. For electronic records an
electronic signature can be used.
Electronic Signature - ANSWER -An electronic signature or e-signature is "any
electronic process signifying an approval or terms and/or documentation presented
in electronic format." Methods of electronically signing documentation include a
digital signature, a digitized image of a signature, a bio-metric identifier such as a
fingerprint or retinal scan, or a code or password.
Qualitative Analysis - ANSWER -In qualitative analysis, HIM personnel carefully
review the quality and adequacy of record documentation and ensure that it is an
accordance with the policies, rules, and regulations established by the facility; the
standards of licensing and accreditity bodies; and government requirements.
, Open-record review - ANSWER -When qualitative analysis is done while the
patient is in the facility or under active treatment, it is called open-record review,
ongoing records review, point-of-care review, or continuous record review.
Closed-record review - ANSWER -The qualitative review is done retrospectively
following discharged or termination of treatment.
Delinquent Health Records - ANSWER -Those records that are not completed
within the specified time frame, for example, within 14 days of discharge. The
definition of a delinquent chart varies according to the facility, but most facilities
require that records be completed within 30 days of discharge as mandated by
CMS regulations and Joint Commission standards. The Joint Commission specifies
that the number of delinquent records cannot exceed 50 percent of the average
number of discharges.
Clinical Documentation Improvement - ANSWER -A process to facilitate the
accurate representation of a patient's clinical status in the patient health record that
is then transformed into coded data.
Diagnosis and procedure codes - ANSWER -* Medicare severity diagnosis-related
groups (ms-drg)
* Value-based purchasing (vbp)
* Quality of care measures including inpatient quality reporting (iqr)
* Severity of illness (soi)
* Expected risk of mortality (rom)
* Present on admission (poa) or hospital-acquired condition (hac) reporting
*Patient saftey measures
* Utilization of resource measures such as case-mix and medical necessity
* Protection from liability
* Public health monitoring
CDI Program - ANSWER -Function is to initiate concurrent and, as appropriate,
retrospective reviews of health records fro conflicting, incomplete, or nonspecific
provider documentation.
