Chapters 4 to 7 Sayles Review Quiz
Index
A/n ___________________ is a list that provides guidance indication, or other references of information contained in a database? a. Map b. Mining c. Element d. Index
Query
A/n ________________________ is a communication tool that during clinical documentation improvement is used to communicate between a clinical documentation improvement professional and the provider? a. Query b. Outcomes and Assessment Information Set (OASIS) c. Data Elements for Emergency Department Systems (DEEDS) d. Uniform Ambulatory Care Data Set (UACDS)
Conditions of Participation
What standard does a hospital that participates in the Medicare and Medicaid programs have to comply with that hospitals who do not accept Medicare and Medicaid patients do not? a. Medical bylaws of the healthcare provider organization b. Conditions of Participation c. Accreditation organization d. Documentation standard
NPDB (National Practitioner Data Bank)
Which database must a healthcare facility query as part of the credentialing process when a physician initially applies for medical staff privileges? a. UHDDS b. MEDPAR c. HEDIS d. NPDB
(Commission on Accreditation of Rehabilitation Facilities) CARF
Which group focuses on accreditation of rehabilitation programs and services? a.HFAP b.Joint Commission c.AAAHC d.CARF
Hybrid records
Which health record format is most commonly used by healthcare settings as they transition to electronic records? a.Integrated records b.Problem-oriented records c.Hybrid records d.Paper records
Safe Medical Devices Act of 1990
Which law requires the reporting of deaths and severe complications due to devices? a. Medical Implantation and Transplantation Act of 1986 b. Medical Devices Reporting Act of 1972 c. Food and Drug Modernization Act of 1997 d. Safe Medical Devices Act of 1990
Healthcare Cost and Utilization Project (HCUP) (A family of databases and related software tools and products developed through a Federal-State-Industry partnership and sponsored by AHRQ.HCUP databases are derived from administrative data and contain encounter-level, clinical and nonclinical information including all-listed diagnoses and procedures, discharge status, patient demographics, and charges for all patients, regardless of payer )
Which national database includes data on all discharged patients regardless of payer? a. Healthcare Cost and Utilization Project b. Medicare Provider Analysis and Review file c. Unified Medical Language System d. Uniform Hospital Discharge Data Set
Disease index
Which of the following contains a list maintained in diagnosis code number order of patients discharged from a facility during a particular time period? a. Physician index b. Master patient index c. Disease index d. Operation index
Operation index
Which of the following contains a list maintained in procedure code number order of patients discharged from a facility during a particular time period? a. Physician index b. Master patient index c. Disease index d. Operation index
Uniform Hospital Discharge Data Set (UHDDS)
Which of the following datasets was created to collect uniform data across the United States for inpatient patient stays? a. Uniform Ambulatory Care Data Set (UACDS) b. Outcomes and Assessment Information Set (OASIS) c. Data Elements for Emergency Department Systems (DEEDS) d. Uniform Hospital Discharge Data Set (UHDDS)
Interoperability
Which of the following describes the capability for two or more electronic systems to communicate and exchange information electronically? a. Sharing b. Interchange c. Mapping d. Interoperability
American Psychiatric Association
Which of the following developed the Diagnostic and Statistical Manual of Mental Disorders? a. Mental Health Association b. American Psychiatric Association c. Mental Health Foundation d. World Psychiatric Association
Document imaging
Which of the following electronic record technological capabilities would allow a paper-based x-ray report to be accessed? a.Database management b.Document imaging c.Text processing d.Vocabulary standards
Operative report
Which of the following includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed? a.Operative report b.Anesthesia report c.Pathology report d.Laboratory report
Database
Which of the following is a collection of data that is organized in a manner to be accessed managed, reported, and updated electronically? a. Dataset b. Database c. Data map d. Data index
Disease Registry (Disease registries are collections of secondary data related to patients with a specific diagnosis, condition, or procedure. Registries are different from indexes in that they contain more extensive data.)
Which of the following is a collection of secondary data related to patients with a specific diagnosis condition, or procedures? a. Disease index b. Disease registry c. Master patient index d. Trauma registry
National Ambulatory Medical Care Survey (Data in the National Hospital Care Survey is a combination of data from the National Hospital Discharge Survey (NHDS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS))
Which of the following is a database from the National Health Care Survey that uses the patient health record as a data source? a. National Health Provider Inventory b. National Ambulatory Medical Care Survey c. National Employer Health Insurance Survey d. National Infectious Disease Inventory
Documenting the patient's health history in detail (Rationale: The discharge summary provides information needed for the continuity of care)
Which of the following is a function of the discharge summary? a. Providing information about the patient's insurance coverage b. Ensuring the other healthcare providers know what to do next while the patient is hospitalized c. Providing information to support the activities of the medical staff review committee d. Documenting the patient's health history in detail
Assisted living facility (Rationale: A community mental health center is an example of a long-term care setting.)
Which of the following is an example of a long-term care setting? a. Assisted living facility b. Ambulatory surgery center c. Community mental health center d. Acute care hospital
Patient's address
Which of the following is an example of administrative information? a.Admitting diagnosis b.Blood pressure records c.Medication records d.Patient's address
Notice of privacy practices (Under the Privacy Rule of HIPAA, healthcare providers must provide patients notice that tells them how the healthcare provider will use or disclose their PHI, as well as how the healthcare provider will safeguard the PHI in its possession and what HIPAA rights the patient can exercise.)
Which of the following is an example of an acknowledgement? a.General consent to treat document b.Notice of privacy practices c.Consultation report d.Patient instructions document
Public health department
Which of the following is an external user of data? a. Public health department b. Medical staff c. Hospital administrator d. Director of the clinical laboratory
Physician orders
Which of the following is clinical data? a.Patient consent b.Physician orders c.Patient registration d. Name of insurance company
MEDPAR (The Medicare Provider Analysis and Review (MEDPAR) File is made up of acute care hospital and skilled nursing facility (SNF) claims data for all Medicare claims. Frequently used for research on topics such as charges for particular types of care and MS-DRGs)
Which of the following is made up of claims data from Medicare claims submitted by acute care hospitals and skilled nursing facilities? a. NPDB b. MEDPAR c. HIPDB d. UHDDS
Individual's rights
Which of the following is one of the principles of data stewardship as defined by the National Committee on Vital and Health Statistics (NCVHS)? a. Individual's rights b. Accuracy of patient information c. Individual's responsibilities d. Completeness of patient information
Database life cycle
Which of the following is the process of execution implementation, and management of databases within healthcare? a. Database management b. Database elements c. Database life cycle d. Database operations cycle
LOINC
Which of the following is the standard for clinical lab test results under the Meaningful Use program? a. CPT b. LOINC c. ICD-10-PCS d. HCPCS Level II
Time and means of the patient's arrival
Which of the following materials is documented in an emergency care record? a.Minimum Data Set b.Time and means of the patient's arrival c. Patient's complete medical history d.APGAR
The reason for the change should be noted
Which of the following statements is true of the process that should be followed in making corrections in paper-based health record entries? a. Addendum should be backdated b. The reason for the change should be noted c.The incorrect information should be obliterated d.The phrase late entry should be noted on the entry
Subacute care
Which of the following types of facilities is generally governed by long-term care documentation standards? a.Rehabilitation b. Subacute care c.Behavioral health d.Ambulatory surgical center
Chief complaint
Which part of a medical history, documents the nature and duration of the symptoms that caused a patient to seek medical attention as stated in that patient's own words? a.Chief complaint b.Social and personal history c.Past medical history d.Present illness
SNOMED CT (comprehensive clinical terminology that provides clinical content and expressivity for clinical documentation and reporting" )
Which standard is attached to the data element smoking status contained in the Common Clinical Data Set? a. ICD-10-CM b. HCPCS Level II c. ICD-10-PCS d. SNOMED CT
Birth defect
Which type of registry is used to collect information on an infant born with spina bifida? a. Operation b. Newborn c. Birth defect d. Trauma
Expressed consent
Written or spoken permission to proceed with care is classified as ___________. a.Expressed consent b.Acknowledgment c.Advance directive d.Implied consent
Clinical Care Classification
___________ is a nursing terminology. a. International Classification of Procedures b. Clinical Care Classification c. International Classification of Functioning d. International Classification of Diseases
Informed Consent (When a treatment or procedure becomes progressively more risky or invasive, it is important that informed consent be completed to ensure the patient has a basic understanding of diagnosis and the nature of the treatment or procedure, along with the risks, benefits, alternatives (including opting out of treatment), and individuals who will perform the treatment or procedure. Informed consent is a process and it is the responsibility of the provider who will be rendering the treatment or performing the procedure to obtain the patient's informed consent and answer the patient's questions. Failure to obtain informed consent can result in legal action generally based on negligence (Klaver 2012).)
It is the process by which the healthcare provider informs or makes the patient knowledgeable about the risks and benefits of the proposed treatment or procedure. a.Informed consent b.Acknowledgment c.Advance directive d.Implied consent
Metathesaurus
LOINC would be found in the UMLS ____________. a. Terminology Network b. SPECIALIST Lexicon c. Semantic Network d. Metathesaurus
Medical history
(Chapter 4) Which of the following creates a chronological report of the patient's condition and response to treatment during a hospital stay? a.Physical examination b.Progress notes c.Physician order d.Medical history
Classifications
(Chapter5) If data aggregation is the goal of collecting the data, ______ are the best choice. a. Classifications b. Code systems c. Clinical terminologies d. Nomenclatures
Radiology Information System
(Chapter6) Which of the following is an example of an electronic data source in healthcare? a. Radiology Information System b. Patient consent for treatment c. Dictation system d. Patient's driver's license
North American Association of Central Cancer Registries
(Chapter7) Which of the following has a certification program for state population-based registries? a. Centers for Disease Control and Prevention b. American College of Surgeons c. North American Association of Central Cancer Registries d. National Trauma Registries Association
NCHS
The ___________ is responsible for the development and maintenance of ICD-10-CM. a. NCHS b. CMS c. ICD-10 C&M Committee d. NCHS and CMS
CMS
The ___________ is responsible for the publishing and maintaining HCPCS Level II. a. CMS b. AMA c. NCHS d. ADA
Accuracy
The ______________ characteristic of quality data is the data being completely free from any errors? a. Accuracy b. Precision c. Comprehensiveness d. Consistency
Data stewardship
The evaluation of data collected based on business needs and strategy is part of _______. a. Data ownership b. Data stewardship c. Data quality b. Data modeling
Organizations that treat Medicare or Medicaid patients
The federal Conditions of Participation apply to which type of healthcare organization? a.Organizations that are accredited b.Organizations that provide acute care services c. Organizations that treat Medicare or Medicaid patients d.Organizations that are subject to the Health Insurance Portability and Accountability Act
The overall information governance model
The management of health information is a fundamental component of which of the following? a.The overall information governance model b.The EHR workflows c.The documentation standards d.Cloud Computing
Ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient
The overall goal of documentation standards is to ______________. a. Ensure physicians have access to the health record information they need to care for the patient b. Ensure that the healthcare provider organization is reimbursed appropriately by payers c. Ensure that the Centers for Medicare and Medicaid Services (CMS) do not find reason to fine the healthcare provider organization d. Ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient
System characterization (The process of creating an inventory of all systems that contain data, including documenting where the data are stored, what type of data are created or stored, how they are managed, with what hardware and software they interact, and providing basic security measures for the systems)
The process of completing an inventory of all electronic systems that create transmit, and store health information is known as what? a. System management b. Data mapping c. Data Mapping d. System characterization
Clinical documentation improvement
The process that focuses on the improving the quality and integrity of patient data while supporting timely coding and reimbursement is known as ________. a. Data collection and accuracy process b. Data quality management c. Clinical documentation improvement d. Clinical quality enhancement
True
True or false. Structured data is data that is entered into a specific format that is capable of being read and analyzed without human intervention. a. True b. False
True
True or false. The master patient index is maintained by the healthcare organization and contains patient demographic information such as name, date of birth, and health record number. a. True b. False
True
True or false. The oversight of the definition of structure of data elements as well as the creation storage, and transmission of data elements is referred to as data management. a. True b. False
False (Forms design)
True or false. The process of creating paper forms to serve a business need is referred to as form creation. a. True b. False
True
True or false. The term that refers to an individual's ability to analyze assess, and reconstruct a situation to provide a solution is critical thinking. a. True b. False
Birthsdeaths, fetal deaths, marriages, and divorces
Vital statistics include data on ___. a. Research projects in which new treatments and tests are investigated to determine whether they are safe and effective. b. Birthsdeaths, fetal deaths, marriages, and divorces c. Medicare claims d. Outcomes
International Classification of Functioning (ICF)
WHO defines ___________ as a reference classification. a. SNOMED CT b. DSM-5 c. ICF d. ICD-O-3
National Library of Medicine The National Library of Medicine (NLM) has developed the database, available on the Internet for use by both patients and practitioners. Mandated by the Food and Drug Administration Modernization Act of 1997; The world's largest medical library and a branch of the National Institutes of Health)
What agency is responsible for developing the clinical trials database? a. National Library of Medicine b. Agency for Healthcare Research and Quality c. Healthcare Cost and Utilization Project d. MEDLINE
Information governance
What concept refers to the process of creating management and oversight of data assets to support the organization's mission vision, and values? a. Enterprise information management b. Outcomes and Assessment Information Set (OASIS) c. Information governance d. Data governance
Precision
What data quality characteristic is met when documenting the specific height of a patient within the health record? a. Comprehensiveness b. Precision c. Definition d. Relevancy
Medical staff bylaws
This document defines how records and documentation are assembled and authenticated within the hospital. a. Ancillary staff bylaws b. Provider contracts c. Hospital bylaws d. Medical staff bylaws
Clinical terminology
A ___________ is a set of terms representing the system of concepts for the medical field. a. Clinical terminology b. Code system c. Nomenclature d. Classification
Allow collection and reporting of healthcare statistics
A classification provides clinical data to ______________. a. Allow collection and reporting of healthcare statistics b. Indicate smoking status in the Common Clinical Data Set c. Facilitate electronic data collection at the point of care d. Use for primary data purposes
Assess the legal environment, system limitations, and HIE agreements
A healthcare provider organization, when defining its legal health record must ___________. a.Assess the legal environment, system limitations, and HIE agreements b.Determine what other healthcare provider organizations are doing c.Determine if a legal health record is needed d.Only include the paper components of the health record
Long-term care
A patient's registration forms, personal property list, RAI/MDS and care plan and discharge or transfer documentation would be found most frequently in which type of health record? a.Rehabilitative care b.Ambulatory care c.Behavioral health d.Long-term care
Includes information from more than one facility in a particular geopolitical area such as a state or region
A population-based registry ___. a. Includes information from more than one facility in a particular geopolitical area such as a state or region b. Includes only cases for a particular facility such as a hospital or clinic c. Represents a computerized system that was developed for a particular facility d. Provides data for comparisons in survival rates and quality of life for patients with different treatments and at different stages of cancer
Code system
An accumulation of numeric or alphanumeric representations or codes for exchanging or storing information is a ___________. a. Nomenclature b. Code system c. Concept system d. Data set
Implied consent
Consent that is inferred by the patient's action or inaction and most commonly asserted by the patient when he or she presents to the emergency department. (the patient sticks out his or her arm in order for the nurse to take a blood pressure.) a.Expressed consent b.Acknowledgment c.Advance directive d.Implied consent
American College of Surgeons
Cancer registries receive approval as part of the facility cancer program from which of the following agencies? a. American Cancer Society b. National Cancer Registrar's Association c. National Cancer Institute d. American College of Surgeons
Identify patients who have been seen or treated in a facility for a particular disease or condition for inclusion in a registry
Case finding is a method used to ___. a. Identify patients who have been seen or treated in a facility for a particular disease or condition for inclusion in a registry b. Define which cases are to be included in a registry c. Identify trends and changes in the incidence of disease d. Identify facility-based trends
Surgery
Category I CPT includes which of the following? a. HCPCS Level II b. Surgery c. Drugs d. Durable medical equipment
Form tracking system
What does a healthcare organization create when it has a unique numbering system to identify all forms used within the organization? a. Forms standardization system b. Forms distribution system c. Forms quality management system d. Form tracking system
Accreditation
What is the end result of a review process that shows voluntary compliance with guidelines of an external, non-profit organization? a.Accreditation b.Certification c.Licensure d.Deemed status
Demographic data
What is the information identifying the patient (such as name health record number, address, and telephone number) called? a. Accession data b. Indicator data c. Reference data d. Demographic data
true (The creation of data models and defining the use of data in relation to business mission and vision allows for the support of data standardization across the organization.)
True or false. Data modeling is the process of creating documentation to document any business decisions made on data collection and storage systems for data. a. True b. False
Patient care quality
Documentation standards have become more detailed and have become focused on ________. a. EHR technology b. Licensure requirements c. Patient care quality d. Accreditation standards
False
True or false. Information is single elements that define a specific characteristic about a patient. a. True b. False
clinical terminologies
If data granularity, or the detail is the goal, then ________ are the best option. a. Classifications b. Code systems c. Clinical terminologies d. Nomenclatures
False (Enterprise information management)
True or false. Organization information management is the processes and functions created by an organization to help plan organize, and coordinate people, processes, technology, and content to manage information systems. a. True b. False
CPT and HCPCS Level II
HCPCS is made up of which code systems? a. CPT and HCPCS Level II b. Dental codes and HCPCS Level II c. ICD-10-PCS, CPT and HCPCS Level II d. CPT, HCPCS Level II and HCPCS Level III
Outcomes and Assessment Information Set
Home health agency process and improvement outcome measures are based on data from the _____. a. Home Health Compare Data Set b. Outcomes and Assessment Information Set c. Uniform Hospital Discharge Data Set d. Common Clinical Data Set
Inpatient procedures
ICD-10-PCS is a classification of _________. a. Emergency room procedures b. Nursing procedures c. Inpatient procedures d. Outpatient procedures
RxNorm
If you were looking for a code for a medication taken orally, in which system is it found? a. ICD-10-CM b. HCPCS Level II c. RxNorm d. ICD-10-PCS
Is the number assigned to each case as it is entered into a cancer registry. (When a case is first entered in the registry, an accession number is assigned. This number consists of the first digits of the year the patient was first seen at the facility, and the remaining digits are assigned sequentially throughout the year)
In a cancer registry the accession number ___. a.,Identifies all the cases of cancer treated in a given year. b.Is the number assigned to each case as it is entered into a cancer registry. c.Identifies the pathologic diagnosis of an individual cancer d.Is the number assigned for the diagnosis of a cancer patient entered into the cancer registry
Unified Medical Language System (This process allows links to be made between different information systems for purposes such as electronic health record systems. UMLS is of particular interest to the HIM manager because of medical vocabularies such as ICD-10-CM, CPT, and the Healthcare Common Procedure Coding System (HCPCS).)
Integration of biomedical concepts from many sources is performed by which of the following? a. Healthcare Cost and Utilization Project b. Medical Literature Analysis, and Retrieval System Online c. Agency for Healthcare Research and Quality d. Unified Medical Language System
Common Clinical Data Set
The ________ originated from federal reporting requirements tied to certification criteria found in the Meaningful Use regulations. a. Outcomes and Assessment Information Set b. Healthcare Effectiveness Data and Information Set c. Common Clinical Data Set d. Uniform Hospital Discharge Data Set
Clinical observations
One of the two major groups of LOINC content is _________. a. Clinical drugs b. Clinical diagnoses c. Clinical observations d. Clinical interventions
ICD-O-3
The _________ is a system for classifying the topography and morphology of neoplasm. a. ICD-O-3 b. ICD-10-CM c. ICD-10 d. SNOMED CT
Concept (concepts, descriptions,relationship)
The ___________ is a core component of SNOMED CT. a. Identifier b. Hierarchy c. Concept d. Definition
Laboratory findings
Results of a urinalysis and all blood tests performed would be found in what part of a healthcare record? a.Autopsy report b.Laboratory findings c.Pathology report d.Surgical report
Case-finding (a method used to identify the patients who have been seen or treated in the facility for the particular disease or condition of interest to the registry. After cases have been identified, extensive information is abstracted from the patients' paper-based health records into the registry database or extracted from other databases and automatically entered into the registry database.)
Review of disease indexes pathology reports and radiation therapy reports is part of which function in the cancer registry? a. Case definition b. Case-finding c. Follow-up d. Reporting
Appropriate and standardized health record documentation
The Joint Commission places emphasis on ________________. a.Appropriate and standardized health record documentation b.Electronic health record technologies used to support documentation c.Clinical and operational practices related to the health record d.Statutes at both the federal and state level
Medicare claims from acute care hospitals and skilled nursing facilities
The Medicare Provider Analysis and Review file is made up of ___. a. Medical malpractice payments and sanctions taken against providers b. Data collected from a sample of office-based physicians c. Medicare claims from acute care hospitals and skilled nursing facilities d. Data collected on births and deaths
Preferred term
The SNOMED CT _________ includes the semantic tag. a. Definition b. Preferred term c. Synonym d. Fully specified name
Problem-oriented health record
The Subjective, Objective, Assessment Plan (SOAP) came from the: a. Source-oriented health record b. Problem-oriented health record c. Hybrid health record d. Depends on facility policy
Acute inpatient
The UHDDS's core data elements were incorporated into the ___________ prospective payment system. a. Outpatient b. Long-term care c. Inpatient rehabilitation d. Acute inpatient
National Library of Medicine (NLM)
The _______ is responsible for development and maintenance of RxNorm a. AMA b. ONC c. FDA d. NLM
Acute care hospitals (Clinics and hospitals collect the standardized HEDIS (Healthcare Effectiveness Data and Information System) data elements from health records.)
The standardized HEDIS data elements are collected by _________. a. Acute care hospitals b. Certified survey vendors c. Healthcare purchasers d. Consumers
Data integrity
This concept includes the process of data governance, patient identification, authorization validation, amendments and record corrections, and audit validation. a. Data reliability b. Data accuracy c. Data integrity d. Data completeness
