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Hospital B Has a Medical Record That Has Computerized the Progress

question 50

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Hospital B has a medical record that has computerized the progress notes, physician orders, ancillary reports, and nursing notes. The coders must review the record and enter abstracting data into the coding system. What type of record is being used at this facility?


Definitions:

Relied

The act of depending on or trusting in something or someone.

False Representation

The act of deliberately presenting false information or deceiving others about a fact, product, or situation.

Arm's Length Transaction

An arm's length transaction is a deal in which the buyers and sellers of a product act independently and have no relationship to each other, ensuring that both parties act in their own self-interest.

Special Duties

Obligations or responsibilities that are distinctive to a particular role, profession, or situation, often beyond ordinary duties.

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