A 16-year-old male was treated at your facility for a closed head injury. The patient’s 18-year-old wife accompanied him to the hospital and signed the consent for admission and treatment because of the patient’s incapacity at the time. The patient has requested that copies of his medical records be sent to his attorney. Who should sign the authorization to release the records?

In the past, Joint Commission standards have focused on promoting the use of a facility approved abbreviation list to be used by hospital care providers. With the advent of the Commission’s national patient safety goals, the focus has shifted to the 

Postage charges in the Health Information Department have increased during the last quarter. The department director has seen metered envelopes in the mail bin that do not appear to be those used for departmental business. The best course of action for the director would be to

The formula used to calculate the percentage of ambulatory care visits made with same day appointments is

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?

Which of the following data sets would be most helpful in developing a home health data registry?  

A pharmacist at your facility was caught running a drug ring. The pharmacist filled orders of valuable medications with cheap outdated ones purchased on the Internet and then sold the good drugs for profit. Patients have been injured and the lawsuits are starting. Unfortunately, your facility is going to be held responsible for the pharmacist’s negligent acts under the doctrine of

In preparation for conversion to a computerized patient record, a committee at your facility is defining each of the data elements in a patient record to determine which elements should be required and to set parameters for each element. The committee is working on the data

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

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: