Case Study-You have been given the responsibility of populating the deficiency a
ID: 428444 • Letter: C
Question
Case Study-You have been given the responsibility of populating the deficiency and form types that will be used by your new chart deficiency system. The old system has such poor data quality that you are starting from scratch. In the current system, the deficiency type and form number have no logical meaning. For example, the form type of “X” means operative note and “P” is cancer staging form. You have been provided with the template in Tables 5-9 and 5-10. Fill in the tables below and be sure to choose logical codes whenever possible. You may add more rows if necessary.
5-9: Deficiency Type (think of common deficiencies such as signature, date, dictation, etc.)
Deficiency Type
Deficiency Code
Deficiency Description
Ex: T
Transcribe
5-10: Form Type (think of various forms used within a hospital such as orders, notes, summaries, queries, etc.)
Form Type
Form Code
Form Description
Ex: OP
Operative Note
Deficiency Type
Deficiency Code
Deficiency Description
Ex: T
Transcribe
Explanation / Answer
5-9: Deficiency Type (think of common deficiencies such as signature, date, dictation, etc.)
Deficiency Type
Deficiency Code
Deficiency Description
Ex: T
Transcribe
SIG
Signature
DT
Date
DIC
Dictation
INP
Inpatient
OTP
Out patient
SOF
Summary of findings
CL N
Clinical note
FI
Further investigations
PA
Patient age
PV
Patient vitals
5-10: Form Type (think of various forms used within a hospital such as orders, notes, summaries, queries, etc.)
Form Type
Form Code
Form Description
Ex: OP
Operative Note
AR
Admission record
SS
Summary sheet
DS
Discharge summary
HOF
History of findings
CF
Consent form
NC
Nurses chart
DC
Drug chart
FC
IV Fluid chart
PS
Progress sheet
DO
Doctors orders
CR
Consultation request
Deficiency Type
Deficiency Code
Deficiency Description
Ex: T
Transcribe
SIG
Signature
DT
Date
DIC
Dictation
INP
Inpatient
OTP
Out patient
SOF
Summary of findings
CL N
Clinical note
FI
Further investigations
PA
Patient age
PV
Patient vitals
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