Domain 1: Information Governance

The discharge summary must be completed within ________ after discharge for most patients but within ________ for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for fewer than ________ hours.

30 days, 24 hours, 48 hours A discharge summary must be completed within 30 days after discharge for most patients but within 24 hours for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for less than 48 hours (Reynolds and Morey 2020, 116-117).

Which of the following is a component of the resident assessment instrument?

A standard Minimum Data Set (MDS) The content of the resident assessment instruments (RAIs) is used to collect the necessary information from and about the facility resident. The RAI consists of three basic components: The Minimum Data Set (MDS), the Care Area Assessment (CAA) process, and the RAI utilization guidelines (James 2017b, 325).

A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis, and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured appendix was discovered. The chief complaint was:

Abdominal pain The chief complaint or reason for the visit is the nature and duration of the symptoms that caused the patient's illness and caused the patient to seek medical attention as stated in the patient's own words. In this scenario the patient came in complaining of abdominal pain, so this is the chief complaint (Reynolds and Morey 2020, 109).

The function that includes compiling the pertinent information from the health record, based on predetermined data sets, to enter into a separate database is called:

Abstracting Although registries and databases are almost universally computerized, data collection is sometimes done manually. The most frequent method is abstracting, the process of reviewing the patient health records and entering the required data elements into the database (Sharp and Madlock-Brown 2020, 197).

A number assigned to patients in a cancer registry in the order that the patients are entered in the registry every year (for example, 03-0001) is a(n) ________ number.

Accession An accession number consists of the first digits of the year the patient was first seen at the facility, with the remaining digits assigned sequentially throughout the year. The first case in, for example, might be 09-0001. The accession number may be assigned manually or by the automated cancer database used by the organization. An accession registry of all cases can be kept manually or be provided as a report by the database software (Sharp and Madlock-Brown 2020, 180).

A coding supervisor audits coded records to ensure the codes reflect the actual documentation in the health record. This code auditing process addresses the data quality element of

Accuracy The quality of coded clinical data depends on a number of factors, including accuracy. Accuracy is ensuring that the coded data is free from error and a correct representation of the patient's diagnosis and procedures (Sharp and Madlock-Brown 2020, 202).

Personal information about patients such as their names, ages, and addresses is considered what type of information?

Administrative For elective hospital admissions, the patient or the admitting physician's office staff often provide administrative information and demographic data before the patient comes to the hospital. Alternatively, the patient may provide the information to the hospital's registration staff on the day of admission or through a secure page of the organization's website prior to admission. In the case of an unplanned admission, the patient or the patient's representative provides administrative information. A patient's name, age, and address would be considered administrative data (Johns 2015, 13).

What is a legal document that is used to specify whether the patient would like to be kept on artificial life support if they become permanently unconscious or is otherwise dying and unable to speak for themselves?

Advance directive An advance directive is a written document that describes the patient's healthcare preferences in the event that he or she is unable to communicate directly at some point in the future. The types of advance directives vary by state but typically include living wills, healthcare surrogate designation, durable power of attorney for healthcare, and anatomical donation (James 2017a, 310).

Data that are collected on large populations of individuals and stored in a database without identifying any particular patient individually are referred to as:

Aggregate data Aggregate data are used to develop information about groups of patients without identifying a particular patient individually (Sharp and Madlock-Brown 2020, 176).

An alteration of the health information by modification, correction, addition, or deletion is known as a(n):

Amendment Providers must have a process in place for handling amendments, corrections, and deletions in health record documentation. An amendment is an alteration of the health information by modification, correction, addition, or deletion (Biedermann and Dolezel 2017, 448).

Which of the following is not associated with a typical data dictionary?

An entity-relationship diagram Though data dictionaries can be part of the database design process, they do not include entityrelationship diagrams. Data dictionaries typically have certain types of data and the standards are important to follow (Sharp and Madlock-Brown 2020, 203).

Reviewing a health record for authentication and medical reports is called:

Analysis Analysis is a review of the health record for completeness and accuracy. HIM personnel can remind providers to complete items in the record and to sign orders and progress (Reynolds and Morey 2020, 125).

In data quality management, the process of translating data into information to be utilized by an application is called:

Analysis Data quality management functions involve continuous improvement for data quality throughout an organization and include four key processes for data. These processes are application, collection, warehousing, and analysis. Analysis is the process of translating data into information utilized for an application (Shaw and Carter 2019, 79).

Who is responsible for the content, quality, and authentication of the discharge summary?

Attending physician The physician principally responsible for the patient's hospital care generally dictates the discharge summary. Regardless of who documents it, the attending physician is responsible for the content and quality of the summary and must date and sign it (Jenkins 2017, 155-156).

The process by which a person or entity who authored an EHR entry or document seeks to validate that they are responsible for the data contained within it is called:

Authentication An author is a person or system who originates or creates information that becomes part of the record. Each author must be granted permission by the healthcare entity to make such entries. Not all users will be granted authorship rights into all areas of the electronic health record (EHR). The individual must have the credentials required by state and federal laws to be granted the right to document observations and facts related to the provision of healthcare services. Authentication is a process by which a user (a person or entity) who authored an EHR entry or document is seeking to validate that they are responsible for the data contained within it (Biedermann and Dolezel 2017, 442-443).

The process of providing proof of the authorship of health record documentation is called:

Authentication Authentication is the process of identifying the source of health record entries by attaching a handwritten signature, the author's initials, or an electronic signature and also the proof of authorship that ensures, as much as possible, that log-ins and messages from a user originate from an authorized source (Jenkins 2017, 159).

The EHR indicates that Dr. Anderson wrote the January 12 progress note at 11:04 a.m. We know Dr. Anderson wrote this progress note due to which of the following?

Authorship Authorship is the origination or creation of recorded information attributed to a specific individual or entity acting at a particular time. In other words, documentation in the EHR or other health record must be credited to the individual who created it. This is typically done through the use of a unique user identifier and a password (Sayles and Kavanaugh-Burke 2018, 23).

Borrowing record entries from another source as well as representing or displaying past documentation as current are examples of a potential breach of:

Authorship integrity Authorship is the origin of recorded information that is attributed to a specific individual or entity. Electronic tools make it easier to copy and paste documentation from one record to another or to pull information forward from a previous visit, someone else's records, or other sources either intentionally or inadvertently. The ability to copy and paste entries leads to a record where a clinician may, upon signing the documentation, unwittingly swear to the accuracy and comprehensiveness of substantial amounts of duplicated, inapplicable, misleading, or erroneous information (Amatayakul 2017, 505).

Which of the following terms is used for the process of scanning past health records into the information system so there is an existing database of patient information, making the information system valuable to the user from the first day of implementation?

Backscanning Backscanning is the process of scanning past health records into the DMS so there is an existing database of patient information, making the DMS valuable to the user from the first day of implementation (Sayles and Kavanaugh-Burke 2018, 131).

The Western Hospital Corporation's HIM director wants to compare the time that each of the hospitals in the corporation are spending on chart analysis and determine how they are performing against the best practice standard. The HIM director generated the following data for comparison. What is this comparison process called?

Benchmarking Benchmarking is the systematic comparison of the products, services, and outcomes of one organization with those of a similar organization. Benchmarking comparisons also can be made using regional and national standards if the data collection processes are similar (Shaw and Carter 2019, 42).

Which of the following processes is an ancillary function of the health record?

Biomedical research Biomedical research is considered an ancillary function of the health record (Fahrenholz 2017b, 81-82).

A patient born with a neural tube defect would be included in which type of registry?

Birth defects Birth defects registries collect data on newborns with birth defects. Often population based, these registries serve a variety of purposes. For example, they provide information on the incidence of birth defects to study causes and prevention of birth defects, to monitor trends in birth defects to improve medical care for children with birth defects, and to target interventions for preventable birth defects such as folic acid to prevent neural tube defects (Sharp and Madlock-Brown 2020, 183).

At Memorial Hospital, HIM professionals are located in the nursing stations, where they are responsible for all aspects of health record processing. While the patient is in the facility, the HIM professional does a daily concurrent review of the record. How does this assist the organization?

By helping to remind providers to complete documentation requirements and sign orders, which is easier to do while the patient is still at the facility Concurrent record reviews help to catch incomplete documentation or unsigned orders while the patient is still in-house (Reynolds and Morey 2020, 125).

What document is a snapshot of a patient's status and includes everything from social issues to disease processes as well as critical paths and clinical pathways that focus on a specific disease process or pathway in a long-term care hospital (LTCH)?

Care plan Care plans are required documentation in a long-term care hospital (LTCH). Some LTCHs may use critical paths (or clinical pathways) for specific patients (James 2017a, 311).

Review of disease indexes, pathology reports, and radiation therapy reports is part of which function in the cancer registry?

Case finding Case finding includes the methods used to identify the patients who have been seen and 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 health record and entered into the registry database (Sharp and Madlock-Brown 2020, 179).

A method of documenting nurses' progress notes by recording only abnormal or unusual findings or deviations from the prescribed plan of care is called:

Charting by exception Charting by exception is a method of documenting only abnormal or unusual findings or deviations from the prescribed plan of the care. A complete patient assessment is performed every shift. When events differ from the assessment or the expected norm for a particular patient, the notes should focus on that particular event and include the data, assessment, intervention, and response. The purpose of charting by exception is to reduce repetitive recordkeeping and documentation of normal events (Reynolds and Morey 2020, 114).

A local skilled nursing facility has been working to improve the quality of care it provides to residents. Facility staff have engaged in several PI initiatives recently, and the facility's internal data shows an improvement in quality metrics. The facility administrator is pleased with these findings but is also interested in determining how this facility is performing in contrast to other nearby skilled nursing facilities. Which of the following should the HIM professional use to inform management on how the facility compares to others in the area?

Comparative performance data The HIM professional should do comparative performance data. Comparative performance data, such as nursing home compare in this case, allows facilities to determine how the facility does in comparison to similar facilities. Facilities report their performance and in turn, the facilities have access to data from these measures. The comparison can assure the organization that it is performing up to industry standards or help the organization identify opportunities for improvement (Shaw and Carter 2019, 356-357).

Alex, an HIM analyst, reviews the record of Patty Eastly, a patient in the facility, to ensure that all documents are complete and signatures are present. This is an example of a:

Concurrent review Record reviews that are conducted while a patient is still in the facility are considered concurrent reviews (Reynolds and Morey 2020, 125). Record reviews that are conducted while a patient is still in the facility are considered concurrent reviews (Reynolds and Morey 2020, 125).

One member of the medical staff reviewed a patient's history, examined the patient, and wrote findings and recommendations at the request of another member of the medical staff. The resulting medical report that documents the response of the reviewing medical staff member is a:

Consultation report A consultation report is the documented findings or recommendation for further treatment by a physician or specialist. Consultations are usually performed at the request of the attending physician (Reynolds and Morey 2020, 113).

A core data set developed by the American Society for Testing and Materials (ASTM) to communicate a patient's past and current health information as the patient transitions from one care setting to another is:

Continuity of care record Continuity of care record (CCR) is documentation of care delivery from one healthcare experience to another (Sandefer 2020, 457).

Which of the following is a concept designed to help standardize clinical content for sharing between providers?

Continuity of care record The continuity of care record (CCR) helps standardize clinical content for sharing between providers. A CCR allows documentation of care delivery from one healthcare experience to another (Sandefer 2020, 457).

The director of the health information department wanted to determine the level of physicians' satisfaction with the department's services. The director surveyed the physicians who came to the department. What type of sample is this?

Convenience Researchers use convenience samples when they "conveniently" use any unit that is at hand. For example, HIM professionals investigating physician satisfaction with departmental services could interview physicians who came to the department (White 2020a, 239).

Using the staff turnover information in the following graph, determine the next action the quality council at the hospital should take.

Coordinate a PI team to look into the cause for the high employee turnover rate in year 3 The employee turnover rate is over the internal benchmark for this hospital, so a performance improvement (PI) team should be formed to determine what the causes for this increase were. This increase in the turnover rate represents an opportunity for improvement (Shaw and Carter 2019, 27-28).

This functionality can result in confusion from incessant repetition of irrelevant clinical data.

Copy and paste The technology used to support the EHR can provide many enhancements over the paper record. Technology also presents the potential for weakening the integrity of the information. One such risk occurs with the copy-and-paste forward functionality present in many operating systems and software programs (Biedermann and Dolezel 2017, 449).

Which statistics should a health data analyst recommend to a manager who would like to measure the relationship between length of stay and time to code a health record?

Correlation Correlation is a statistic that is used to describe the association or relationship between two variables (White 2020b, 516).

City Hospital's revenue cycle management team has established the following benchmarks: (1) The value of discharged, not final billed (DNFB) cases should not exceed two days of average daily revenue; and (2) accounts receivable days are not to exceed 60 days. The net average daily revenue is $1,000,000. What do the following data indicate about how City Hospital is meeting its benchmarks?

DNFB cases met the benchmark 50 percent of the time. In this example, DNFB met the benchmark in January, February, and June, which is 3/6 or 50 percent of the time (Handlon 2020, 253).

A method that has been developed for presenting a variety of data on a single display in an easy-toread format is called a:

Dashboard A method that has been developed for presenting a variety of data on a single display in an easyto- read format is called a dashboard (Marc 2020, 538).

Mrs. Smith's admitting data indicates that her birth date is March 21, 1948. On the discharge summary, Mrs. Smith's birth date is recorded as July 21, 1948. Which data quality element is missing from Mrs. Smith's health record?

Data consistency Providers must have a process in place for handling amendments, corrections, and deletions in health record documentation. An amendment is an alteration of the health information by modification, correction, addition, or deletion (Biedermann and Dolezel 2017, 448).

A critical early step in designing an EHR in which the characteristics of each data element are defined is to develop a(n):

Data dictionary A data dictionary is a descriptive list of the data elements to be collected in an information system or database whose purpose is to ensure consistency of terminology (Sharp and Madlock- Brown 2020, 203).

The data that describe other data in order to facilitate data quality are found in the:

Data dictionary The data contained in the data dictionary are known as metadata. Metadata are descriptive data that characterize other data to create a clearer understanding of their meaning and to achieve greater reliability and quality of information (Sayles and Kavanaugh-Burke 2018, 30).

Decision-making and authority over data-related matters is known as:

Data governance Data governance is an emerging practice in the healthcare industry. Decision-making and authority over data-related matters is data governance. It is clear that any industry as reliant on data as healthcare needs a plan for managing this asset (Biedermann and Dolezel 2017, 163).

The HIM director wants to ensure that state regulations are being followed with regard to retention of the health records of minors. Which of the following data management domains would be responsible for ensuring these regulations are followed?

Data life cycle management Data management is based on the assumption that all data have a life cycle. Typical data life cycle functions requiring data governance include: establishing what data are to be collected and how they are to be captured; setting standards for data retention and storage; determining processes for data access and distribution; establishing standards for data archival and destruction (Johns 2020, 82).

In establishing roles and responsibilities within a data governance program, which of the following would normally be embedded within an organization's business unit and be responsible for monitoring the data quality of the unit?

Data steward Data stewards are typically designated throughout the enterprise within business units, including IT (Johns 2020, 93).

A collection of data that is organized so its contents can be easily accessed, managed, and updated is called a:

Database A database is a tool used to collect, retrieve, report, and analyze data. A database cannot function without a database management system (DBMS) to manipulate and control the data stored within the database. Databases allow data to be stored in one place and accessed by many different systems. This reduces the redundancy of data and improves data consistency. The decrease in redundancy leads to improved data quality, which in turn saves time by reducing the duplication of data entry (Sayles and Kavanaugh-Burke 2018, 28).

Records that are not completed by the physician within the time frame specified in the healthcare organization policies are called:

Delinquent records Delinquent health records are those records that are not completed within the specified time frame, for example, within 14 days of discharge. A delinquent record is similar to an overdue library book. 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. Some facilities require a shorter time frame for completing records because of concerns about timely billing (Reynolds and Morey 2020, 128).

Danny, an HIM analyst for Memorial Hospital, is conducting a qualitative analysis of a discharged patient's chart. His goal in this process is:

Determining if the documentation includes all requirements set by CMS, the state, and accrediting bodies Qualitative analysis is conducted to determine whether documentation is complete and includes all components set forth by CMS, state guidelines, and accrediting organization standards. Quantitative analysis determines whether required documentation is present in the chart or not (Reynolds and Morey 2020, 125-126).

A medical group practice has contracted with an HIM professional to help define the practice's legal health record. Which of the following should the HIM professional perform first to identify the components of the legal health record?

Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records The HIM professional should advise the medical group practice to develop a list of statutes, regulations, rules, and guidelines regarding the release of the health record as the first step in determining the components of the legal health records (Rinehart-Thompson 2017c, 171-172).

To ensure authentication of data entries, which type of signature is the most secure?

Digital The digital signature is similar to the electronic signature except that it uses encryption to provide nonrepudiation to prove the authenticator's identity, which makes it most secure (Sayles and Kavanaugh-Burke 2018, 159).

A staff member is assigned to sit in the waiting room of the physician's office to collect data on patient waiting times. The staff member records the time at which the patient comes in the door and when the patient is called to the examining room. This is an example of what type of data collection?

Direct observation Direct observation is a data collection method in which the researchers conduct the observation themselves, spending time in the environment they are observing and recording these observations (Shaw and Carter 2019, 116).

115. Which of the following plans address how information can be documented in the health record during down time or a catastrophic event?

Disaster Disaster recovery planning is the technological aspect of business continuity planning. HIM professionals assist in designing disaster recovery plans that address documenting information in the health record during down time or a disaster (Brinda and Watters 2020, 336).

What information can be determined from the data in the following graph?

Doctor X uses code 99215 less frequently than his peers. These data are showing that Doctor X bills code 99213 primarily and not the other four service codes for established patients. However, the graph tells the reader nothing about Doctor X's documentation which would make answers b and c incorrect. Doctor X does use 99212 less than his peers, not more than his peers. A physician who consistently reports the same level of service for all patient encounters may look suspicious to claims auditors. With the exception of certain specialists, physicians treat all types of patients in their offices, and office treatment requires use of most of the levels of services (Kuehn and Huey 2020, 313-314).

Which of the following data sets would be most useful in developing a matrix for identification of components of the legal health record?

Document name, media type, source system, electronic storage start date, stop printing start date Create a matrix that defines each document type in the legal health record and determine the medium in which each element will appear. Such a matrix could include a column indicating the transition date of a particular document from the paper-based to the electronic environment. It is important that specific state guidelines are incorporated when a facility matrix is developed (Fahrenholz 2017c, 53).

Automated insertion of clinical data using templates or similar tools with predetermined components using uncontrolled and uncertain clinical relevance is an example of a potential breach of:

Documentation integrity Templates often provide clinical information by default and design. When used inappropriately, they may misrepresent a patient's condition and might not reflect changes in a condition. Unless the physician or other authorized provider removes the default documentation from the visit note, a higher level of service than is actually provided could be assigned (Jenkins 2017, 160-161).

Which of the following would not be an appropriate duty for an HIM professional?

Documenting additions or deletions in a patient's record Only healthcare providers should document within the patient's record. However, HIM professionals can monitor documentation guidelines, train healthcare providers in documentation techniques and audit patient records (Reynolds and Morey 2020, 102).

Sue Smith has been admitted to Healthwise Hospital with stroke symptoms. Which professionals on her healthcare team are primarily responsible for documenting diagnosis and treatment information in her record during her hospital stay?

Dr. Helms, her primary physician; and other providers on her care team The answer is a because the primary physician and other direct care providers are the only ones that can document diagnosis and treatment information in the record (Reynolds and Morey 2020, 101, 127).

Which of the following is a graphical display of the relationships between tables in a database?

ERD An entity relationship diagram (ERD) is used to describe how the tables work together. The diagram is a graphic representation of the entities, attributes, and relationships that are part of a database and is a data modeling tool (White 2016a, 46).

What relationships is the following entity relationship diagram showing?

Each division has one hospital, but each hospital has many divisions. This model shows that the relationship between the data table (or entity) hospital and the data table (or entity) division is one-to-many. A one-to-many relationship means that for every instance of hospital stored in the database, many related instances of division may be stored. Reading the diagram in the other direction, each instance of division stored in the database is related to only one instance of hospital (Sayles and Kavanaugh-Burke 2018, 32-33).

A nurse tried to enter a temperature of 134 degrees and the system would not accept it. What is this an example of?

Edit check An edit check is a standard feature in many applications' data entry and data collection software packages. Edit checks are preprogrammed definitions of each data field set up within the application. So, as data are entered, if any data are different from what has been preprogrammed, an edit message appears on the screen (Sayles and Kavanaugh-Burke 2018, 17).

What is a primary purpose for documenting and maintaining health records?

Effective communication among caregivers for continuity of care Federal and state statutes, licensing requirements, and accreditation standards provide minimum guidelines to ensure accurate and complete documentation. Such documentation facilitates effective communication among caregivers to provide continuity of patient care, which is its primary purpose (Fahrenholz 2017e, 1).

What data model is most widely used to illustrate a relational database structure?

Entity-relationship diagram (ERD) Entity relationship modeling is a type of conceptual modeling. Conceptual models are abstract and encourage high-level problem structuring; they help establish a common ground for communication between users and developers. The entity-relationship diagram (ERD) was developed to depict relational database structures (Sharp and Madlock-Brown 2020, 188-189).

As part of the initiative to improve data integrity, the Data Quality Committee conducted an inventory of all the hospital's databases. The review showed that more than 70 percent of the identified databases did not have data dictionaries. Given this data, what should be the committee's first action?

Establish a data dictionary policy with associated standards The results of the inventory indicate a significant problem and should not be ignored. Before in-service training or memos can be developed, the organization's formal position on data dictionaries must be established through development of a policy and associated standards. An organization-wide data dictionary is developed outside the framework of a specific database design process. This data dictionary serves to promote data quality through data consistency across the organization. Individual data element definitions are agreed upon and defined. This leads to better quality data and facilitates the detailed, technical data dictionaries that are integrated with the databases themselves (Sharp and Madlock-Brown 2020, 203).

What type of report would give administrators structured information in a variety of graphs to better plan facility operations?

Executive information system dashboard A dashboard report gives administration-structured information to make intelligent decisions for the future (Sayles and Kavanaugh-Burke 2018, 114-115).

Dr. Jones dies while still in active medical practice. He leaves incomplete records at Medical Center Hospital. The best way for the HIM department to handle these incomplete records is to:

File the incomplete records with a notation about the physician's death Each facility must have a policy in place for dealing with situations where records remain incomplete for an extended period. The HIM director can be given authority to declare that a record is completed for purposes of filing when a provider relocates, dies, or has an extended illness that would prevent the record from ever being completed. Every effort should be made to have a partner or physician in the same specialty area complete the charts so that coding, billing, and statistical information are available (Reynolds and Morey 2020, 106).

The insured party's member identification number is an example of which type of data?

Financial data Financial data includes details about the patient's occupation, employer, and insurance coverage and is collected at the time of treatment. Healthcare providers use this data to complete claims forms that will be submitted to third-party payers (Fahrenholz 2017b, 74-76).

How do healthcare providers use the administrative data they collect?

For regulatory, operational, and financial purposes There are many types of patient-identifiable data elements that are pulled from the patient's healthcare record that are not included in the legal health record or designated record set definitions. Administrative data and derived data and documents are two examples of patientidentifiable data that are used in the healthcare organization. Administrative data are patientidentifiable data used for administrative, regulatory, healthcare operation, and payment (financial) purposes (Fahrenholz 2017a, 56).

Bob Jones is considering contractors for his company's medical benefits, and he is reviewing health plans from two different entities. Which of the following databases should he consult to compare the performance of the two health plans?

HEDIS The Healthcare Effectiveness Data and Information Set (HEDIS) is a set of standard performance measures designed to provide purchasers and consumers of healthcare with the information they need for comparing the performance of managed healthcare plans (Shaw and Carter 2019, 332).

David was admitted to the hospital following an automobile accident in which he suffered a fractured femur. Two days after surgery to repair the fracture, he developed pneumonia and was transferred to the ICU. Because the pneumonia was not present at the time of admission to the hospital, it is considered a:

Healthcare-associated infection A healthcare-associated infection (HAI) is an infection occurring in a patient in a hospital or healthcare setting in whom the infection was not present or incubating at the time of admission, or it is the remainder of an infection acquired during a previous admission (Shaw and Carter 2020, 177).

According to the UHDDS definition, ethnicity should be recorded on a patient record as:

Hispanic, non-Hispanic According to the UHDDS definition, ethnicity should be recorded on a patient record as Hispanic or Non-Hispanic. The UHDDS has been revised several times since 1986 (Schraffenberger and Palkie 2020, 91-92).

Records consisting of multiple electronic systems that do not communicate or are not logically architected for record management are called:

Hybrid health records Hybrid health records are increasingly seen as the most common transition points between fully paper and completely electronic records. Hybrid records may be a mixture of paper and electronic or multiple electronic systems that do not communicate or are not logically architected for record management (Biedermann and Dolezel 2017, 429).

Which of the following is the goal of quantitative analysis performed by health information management (HIM) professionals?

Identifying deficiencies early so they can be corrected Quantitative analysis is a review of the health record to identify deficiencies to ensure completeness and accuracy. It is generally conducted retrospectively, that is, after the patient's discharge from the facility or at the conclusion of treatment (Reynolds and Morey 2020, 125).

A pediatrician would report the fact that he or she administered the MMR vaccine to a toddler on a(n):

Immunization registry Immunization registries usually have the purpose of increasing the number of infants and children who receive proper immunizations at the proper intervals. To accomplish this goal, they collect information within a particular geographic area about children and their immunization status (Sharp and Madlock-Brown 2020, 185-186).

In assessing the quality of care given to patients with diabetes mellitus, the quality team collects data regarding blood sugar levels on admission and on discharge. These data are called a(n):

Indicator An indicator is a performance measure that enables healthcare organizations to monitor a process to determine whether it is meeting process requirements. Monitoring blood sugars on admission and discharge is an indicator of the quality of care delivered to the diabetes patient during the stay (Shaw and Carter 2019, 143).

The leadership and organizational structures, policies, procedures, technology, and controls that ensure that patient and other enterprise data and information sustain and extend the entity's mission and strategies, deliver value, comply with laws and regulations, minimize risk to all stakeholders, and advance the public good is called:

Information governance Information governance is defined as ensuring leadership and organizational practices, resources, and controls for effective, compliant, and ethical stewardship of information assets to enable best clinical and business practices and serve patients, stakeholders, and the public good (Johns 2020, 75-77).

Why could it be difficult for a healthcare entity to respond to pulling an entire, legal health record together for an authorized request for information?

It can exist in separate and multiple paper-based or electronic systems. The documentation that comprises the legal health record (LHR) may physically exist in separate and multiple paper-based or electronic systems. This complicates the process of pulling the entire legal record together in response to authorized requests to produce the complete patient record. Once the LHR is defined, it is best practice to create a health record matrix that identifies and tracks the physical location of each paper document and the source of each electronic document that constitutes the LHR. In addition to defining the content of the LHR, it is best practice to establish a policy statement on the maintenance of it (Rinehart-Thompson 2020, 57-58).

Using the information in these partial attribute lists for the PATIENT, VISIT, and CLINIC columns in a relational database, the attribute PATIENT_MRN is listed in both the PATIENT Entity Attributes and the VISIT Entity Attributes, and CLINIC_ID is listed in both the VISIT Entity Attributes and the CLINIC Entity Attributes. What does the attribute CLINIC_ID represent?

It is the primary key in CLINIC and the foreign key in VISIT. The primary key (PK) for PATIENT, PATIENT_MRN, is repeated in VISIT, as is the PK for CLINIC, CLINIC_ID. These keys are called foreign keys (FK) in the VISIT table. Foreign keys allow relationships between tables. By having the foreign keys in VISIT, the information in PATIENT and CLINIC is linked through the VISIT table (Johns 2015, 127-128).

Using the information in these partial attribute lists for the PATIENT, VISIT, and CLINIC columns in a relational database, the attribute PATIENT_MRN is listed in both the PATIENT Entity Attributes and the VISIT Entity Attributes, and CLINIC_ID is listed in both the VISIT Entity Attributes and the CLINIC Entity Attributes. What does the attribute PATIENT_MRN represent?

It is the primary key in PATIENT and the foreign key in VISIT. The primary key (PK) for PATIENT, PATIENT_MRN, is repeated in VISIT, as is the PK for CLINIC, CLINIC_ID. These keys are called foreign keys (FK) in the VISIT table. Foreign keys allow relationships between tables. By having the foreign keys in VISIT, the information in PATIENT and CLINIC is linked through the VISIT table (Johns 2015, 128-129).

Unstructured data may be preferred over structured data because:

It provides greater detail Unstructured data is often preferred over structured data because it enables providers to document details and nuance that are usually not available with structured data (Biedermann and Dolezel 2017, 159).

The first deliverable from a legal health record (LHR) definition project is a:

List of LHR stakeholders The stakeholder team will drive the creation of the legal health record (LHR) documentation, undertake the LHR definition project, and be responsible for its continued maintenance. Establishment of the stakeholder team should be the first step in the LHR definition process (Biedermann and Dolezel 2017, 430).

In long-term care, the resident's comprehensive assessment is based on data collected in the:

MDS The Minimum Data Set for Long-Term Care is a federally mandated standard assessment form used to collect demographic and clinical data on nursing home residents. It consists of a core set of screening and assessment elements based on common definitions. To meet federal requirements, long-term care facilities must complete an MDS for every resident at the time of admission and at designated reassessment points throughout the resident's stay (James 2017b, 325-326).

A regular review of legal health record policies and procedures to ensure a healthcare entity remains in compliance with legal requirements is generally called a legal health record:

Maintenance plan Regular reviews and updates of related policies and procedures to ensure the organization is always in compliance with the latest rules and trends in the legal health records (LHRs) is part of the LHR maintenance plan (Biedermann and Dolezel 2017, 432).

Anywhere Hospital has mandated that the Social Security number will be displayed in the XXX-XX-XXXX format for their patients. This is an example of the use of a:

Mask The data dictionary may also control if a mask is used and if so, what form it takes. The Social Security number of 123456789 could be entered and it appears in the system as 123-45-6789. The use of the mask tells the database what format to use to display the number (Sayles and Kavanaugh-Burke 2018, 31).

A health data analyst has been asked to compile a report on the percentage of patients who had a baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical reports in the health record would the health data analyst need to consult in order to prepare this report?

Medication administration record and clinical laboratory reports Clinical laboratory reports should be reviewed to determine if a partial thromboplastin time (PTT) test was performed. Medication Administration Records (MAR) should be reviewed to determine if heparin was given after the PTT test was performed (Reynolds and Morey 2020, 114).

Name of element, definition, application in which the data element is found, locator key, ownership, entity relationships, date first entered system, date terminated from system, and system of origin are all examples of:

Metadata Examples of metadata include name of element, definition, application in which the data element is found, locator key, ownership, entity relationships, date first entered system, date terminated from system, and system of origin (Amatayakul 2017, 314-315).

Sue is updating the data dictionary for her organization. In this data dictionary, the data element name is considered which of the following?

Metadata Metadata are often referred to as "data about data." Metadata are structured information used to increase the effective use of data. One of the most familiar types of metadata is used to describe data in databases. Data element name, data type, and field length are examples of this kind of metadata (Johns 2020, 83).

Which of the following would a data analyst use to locate, retrieve, and use data?

Metadata Metadata are often referred to as data about data. Metadata are structured information used to increase the effective use of data. By describing data, metadata makes it easier to locate, retrieve, use, and manage (Johns 2020, 83).

Which of the following is used by a long-term care facility to gather information about specific health status factors and includes information about specific risk factors in the resident's care?

Minimum Data Set The Minimum Data Set (MDS) is a component of the resident assessment instrument (RAI) and is used to collect information about the resident's risk factors and to plan the ongoing care and treatment of the resident in the long-term care facility (James 2017b, 325-326).

Gladys was admitted to Sunshine Nursing Facility for rehabilitation following her hip fracture. Upon admission, the nursing staff assessed Gladys in multiple areas, some of which are cognitive loss, mood, vision function, pain, and the medications she is taking. This information will be recorded in her health record for the:

Minimum data set to plan her care The federal government mandated the use of the Minimum Data Set (MDS) for Long-Term Care to plan the care of long-term care residents. The MDS 3.0 version became effective in 2010. This data set structures the assessment of long-term care residents in the following areas: delirium, cognitive loss and dementia, communication, vision function, activities of daily living function and rehabilitation potential, mood and behavior symptoms, activity-pursuit patterns, treatments and procedures, pain, and medications to name a few (Shaw and Carter 2019, 167).

Pam, a nursing supervisor in the newborn intensive care unit. During her shift, several parents of newborns in the unit are visiting. The neonatologist has also recently been in and has provided orders for several of the newborns. Because of the current workload, another nurse in the unit, Jackie, has asked Pam to help her complete the orders. Pam is asked to administer a medication to one of the newborns that Jackie has already retrieved for the patient. Jackie tells Pam that she has double checked the medication both through bar coding and with the order. Before Pam administers the medication, she scans both the medication and the newborn's patient ID band and learns that she has the incorrect medication for this patient. Pam does not administer that medication but goes back to the order and, through the proper steps, administers the correct medication. Based on this scenario, which of the following occurred?

Near miss The situation presented was a near miss as it did not affect the outcome, but if the wrong drug were to have been administered before the error was caught, it had the change of being a serious adverse event. Near misses include occurrences that do not necessarily affect an outcome, but if they were to recur they would carry significant chance of being a serious adverse event. Near misses fall under the definition of a sentinel event but are not reviewable by the Joint Commission under its current sentinel event policy. Near misses are a valuable tool for evaluation of processes and procedures, especially in high-risk or high-volume areas of facilities (Shaw and Carter 2019, 199).

A physician on your staff asked you to help her collect information about the effects of smoking during pregnancy on the birth weight of babies. You were asked to collect the following information: whether or not the mothers smoke during pregnancy; birth weight of the babies; Apgar scores at one minute; and Apgar scores at five minutes. The scales of these variables would be:

Nominal, ratio, ordinal, ordinal The yes or no question as to whether mother smoked during pregnancy would be nominal data with numbers assigned to them for a calculation. The baby's birth weight is a ratio or scale data because it is a defined unit of measure. The APGAR scores represent ordinal data because the order of the numbers is meaningful (White 2020a, 196-197).

Mrs. Bolton is an angry patient who resents her physician "bossing her around." She refuses to take a portion of the medications the nurses bring to her pursuant to physician orders and is verbally abusive to the patient care assistants. Of the following options, the most appropriate way to document Mrs. Bolton's behavior in the patient health record is:

Noncompliant and hostile toward staff When entries are made in the health record regarding a patient who is particularly hostile or irritable, general documentation principles apply, such as charting objective facts and avoiding the use of personal opinions, particularly those that are critical of the patient. The degree to which these general principles apply is heightened because a disagreeable patient may cause a provider to use more expressive and inappropriate language. Further, a hostile patient may be more likely to file legal action in the future if the hostility is a personal attribute and not simply a manifestation of his or her medical condition (Rinehart-Thompson 2017c, 179).

The practices or methods that defend against charges questioning the integrity of the data and documents are called:

Nonrepudiation The integrity of each piece of data, including any document, must be ensured to maintain highly defensible business records. Document and data nonrepudiation are the methods by which the data are maintained in an accurate form after their creation, free of unauthorized changes, modifications, updates, or similar changes (Biedermann and Dolezel 2017, 443).

Which of the following personnel should be authorized, per hospital policy, to take a physician's verbal order for the administration of medication?

Nurse working on the unit where the patient is located Because of the risks associated with miscommunication, verbal orders are discouraged. When a verbal order is necessary, a clinician should sign, give his or her credential (for example, RN, PT, or LPN), and record the date and time the order was received. Verbal orders for medication are usually required to be given to, and to be accepted only by, nursing or pharmacy personnel (Rinehart-Thompson 2017c, 178).

The basic component of a(n) ________ is an object that contains both data and their relationships in a single structure.

Object-oriented database An object-oriented database is derived from object-oriented programming and has no single inherent structure. The structure for any given class or type of object can be anything a programmer finds useful—a linked list, a set, an array, etc. An object may contain different degrees of complexity, making use of multiple types and multiple structures (Amatayakul 2017, 306).

A database contains two tables: physicians and patients. If a physician may be linked to many patients and patients may only be related to one physician, what is the cardinality of the relationship between the two tables?

One-to-many The one-to-many relationship exists when one instance of an entity is associated with many instances of another entity. If a physician may be linked to many patients and patients may only be related to one physician, this is an example of a one-to-many relationship (Sayles and Kavanaugh-Burke 2018, 33).

The clinical statement "microscopic sections of the gallbladder reveal a surface lined by tall columnar cells of uniform size and shape" would be documented on which health record form?

Pathology report A pathology report is a document that contains the diagnosis determined by examining cells and tissues under a microscope. The report may also contain information about the size, shape, and appearance of a specimen as it looks to the naked eye (Reynolds and Morey 2020, 115).

Which of the following is the unique identifier in the relational database patient table?

Patient number The unique identifier in the patient table is the patient number. It is unique to each patient. Patient last name, first name, and date of birth can be shared with other patients, but the identifier will not (Biedermann and Dolezel 2017, 189).

In a relational database, which of the following is an example of a many-to-many relationship?

Patients to consulting physicians A many-to-many relationship occurs only in a data model developed at the conceptual level. In this case, the relationship between patients and consulting physicians is many-to-many. For each instance of patient, there could be many instances of consulting physician because patients can be seen by more than one consulting physician. For each instance of consulting physician, there could be many patients because the physician sees many patients (Sayles and Kavanaugh-Burke 2018, 33).

Which of the following is an example of a 1:1 relationship?

Patients to hospital beds A one-to-one relationship exists when an instance of an entity (a row or record) is associated with one instance of another entity, and vice versa. There is only one bed per patient and one patient per bed. One-to-one relationships are rare in logical-level data models because they often indicate a separate entity is unnecessary (Sayles and Kavanaugh-Burke 2018, 33).

Identify the level in the data model that describes how the data is stored within the database:

Physical data model The physical data model shows how the data are physically stored within the database. The users are not involved with this level of the database because of its technical complexity (Sayles and Kavanaugh-Burke 2018, 32).

Which of the following indexes would be used to compare the number and quality of treatments for patients who underwent the same operation with different surgeons?

Physician The physician index categorizes patients by primary physician. It guides the retrieval of cases treated by a particular physician. This index is created simply by sorting patients by physician (Fahrenholz 2017c, 124).

It is important for a healthcare entity to have ________ addressing how to deal with corrections made to erroneous entries in health records.

Policies and procedures When erroneous entries are made in health records, policies and procedures should have provisions for how corrections are made. Educating clinicians who are authorized to document in the health record on the appropriate way to make corrections will promote consistency and standardization and maintain the integrity of the health record (Jenkins 2017, 161).

In figuring a drug dosage, it is unacceptable to round up to the nearest gram if the drug is to be dosed in milligrams. Which dimension of data quality is being applied in this situation?

Precision Precision often relates to numerical data. It denotes how close to an actual size, weight, or other standard a particular measurement is (Sharp and Madlock-Brown 2020, 202).

Because a health record contains patient-specific data and information about a patient that has been documented by the professionals who provided care or services to that patient, it is considered:

Primary data source The health record is considered a primary data source because it contains patient-specific data and information about a patient that has been documented by the professionals who provided care or services to that patient (Fahrenholz 2017c, 128).

Who is responsible for ensuring the quality of health record documentation?

Provider The provider is responsible for ensuring the quality of the documentation of the healthcare record (Rinehart-Thompson 2017c, 177).

What term is used in reference to the systematic review of sample health records to determine whether documentation standards are being met?

Qualitative analysis Qualitative analysis is a review of the health record to ensure the adequacy of entries documenting the quality of care are present (Hunt 2017, 201).

The following data have been collected by the hospital quality council. What conclusions can be made from the data on the hospital's quality of care between the first and second quarters?

Quality of care declined between the first and second quarters. This type of data would be found on a dashboard report provided to the hospital's board of directors. The measures show a dramatic change in patient safety issues at this organization. The increase in each measure result supports a decline in overall quality of care. The board would now need to investigate to determine why these changes occurred (Shaw and Carter 2019, 322-323).

The HIM manager tasked the coding manager to development a dashboard that shows the discharges pending final billing so that she can plan for staffing. Because this data changes throughout the day, what analysis technique is needed?

Real-time analytics As data analysis tools have become more mature and the granularity of the data available in a healthcare entity increases, real-time analytics and performance improvement dashboards based on key performance indicators (KPIs) are becoming the norm. This analysis technique is used in this scenario by the coding manager (White 2020b, 523).

While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on the:

Reason on encounter The Uniform Ambulatory Care Data Set (UACDS) includes data elements specific to ambulatory care such as the reason for the encounter with the healthcare provider (Johns 2015, 280).

As part of his role at the local hospital, Jake is reviewing Joint Commission standards to ensure that the organization is meeting the accreditation requirements. As part of the review, Jake is looking at a specific set of standards that are primarily focused on documentation. Some of the standard requirements include care provided, procedures that were done on the patient, and the progress of the patient. Based on this scenario, which set of Joint Commission standards is Jake reviewing?

Record of care standards Based on the content in the scenario, it can be deduced that Jake is reviewing the record of care standards. These standards should be detailed enough so the patient can be identified and should also support the care provided to include diagnosis, treatments, care results, and communication between staff. Care providers should also document patient progress in the patient record. This information is used to make care decisions (Shaw and Carter 2019, 360).

Which of the following represents dataflow for a hospital inpatient admission?

Registration > services performed > charges recorded > diagnostic and procedure codes assigned The data flow for a hospital inpatient can begin in several ways. Data collection starts in the registration department if patients are a direct admission for their physician's office or hospital outpatient department. Data collection begins in the emergency room if the patients arrive at the hospital, are assessed in the emergency room, and are admitted as an inpatient. No matter where the data collection begins, the same patient demographic information is collected. During the course of the inpatient stay, patient care is delivered and data is captured. As care is delivered and procedures are performed, charges are entered either by nursing staff or the personnel performing the procedure. After the patient is discharged, diagnosis and procedure codes are assigned (White 2016a, 23-24).

Which of the following are considered dimensions of data quality?

Relevancy, granularity, timeliness, currency, accuracy, precision, and consistency Common characteristics of data quality are relevancy, granularity, timeliness, currency, accuracy, precision, and consistency (Sharp and Madlock-Brown 2020, 202).

Two clerks are abstracting data for a registry. When their work is checked, discrepancies are found between similar data abstracted by the two clerks. Which data quality component is lacking?

Reliability Reliability is a measure of consistency of data items based on their reproducibility and an estimation of their error of measurement (Sharp and Madlock-Brown 2020, 202).

According to Joint Commission Accreditation Standards, which document must be placed in the patient's record before a surgical procedure may be performed?

Report of history and physical examination Except in emergency situations, every surgical patient's chart must include a report of a complete history and physical before the surgery is to be performed (Reynolds and Morey 2020, 110).

According to accreditation standards, which document must be placed in the patient's record before a surgical procedure may be performed?

Report of history and physical examination Medicare Conditions of Participation require that admitting physicians perform an initial physical examination within 24 hours of admission. Documentation of medical history, consents, and the physical examination must be available in the patient's record before any surgical procedures can be performed (Reynolds and Morey 2020, 110).

To complete a comprehensive assessment and collect information for the Minimum Data Set for Long-Term Care, the coordinator must use which of the following?

Resident Assessment Instrument Every long-term care facility must complete a comprehensive assessment of every resident's needs by using the resident assessment instrument (RAI) (James 2017b, 325).

In a long-term care setting, these are problem-oriented frameworks for additional patient assessment based on problem identification items (triggered conditions):

Resident Assessment Protocols (RAPs) Resident assessment protocols (RAPs) form a critical link to decisions about care planning and provide guidance on how to synthesize assessment information within a comprehensive assessment. The triggers target conditions for additional assessment and review, as warranted by Minimum Data Set (MDS) item responses. The RAPs guidelines help facility staff evaluate triggered conditions (James 2017b, 328).

General Hospital is performing peer reviews of its medical providers for quality outcomes of care. The hospital has over 500 providers on its medical staff. The process to review even 10 cases for each provider is quite extensive. The quality department has concluded that, to accomplish this review process, it will review 20 percent of each provider's inpatient admissions to the hospital on an every-other-year rotation. In this situation, the quality department has applied which of the following techniques to its review process?

Sampling Sometimes, the organizational characteristic or parameter about which data are being collected occurs too frequently to measure every occurrence. In this case, those collecting the data might want to use sampling techniques. Sampling is the recording of a smaller subset of observations of the characteristic or parameter, making certain, however, that a sufficient number of observations have been made to predict the overall configuration of the data (Shaw and Carter 2019, 72).

In order to set the budget for next year, the hospital administrator tasked a business analyst with determining the average charges and average length of stay for Medicaid patients. The business analyst uses hospital claims data for this analysis and provides the results to the administrator. What type of data are the claims data in this case?

Secondary data The claims data is secondary data, that is, the data are used for a purpose that was not the primary reason for collection (White 2020b, 520).

When data is taken from the health record and entered into registries and databases, the data in the registries or databases is then considered a(n):

Secondary data source Secondary data sources provide information that is not readily available from individual health records. Data taken from health records and entered into disease-oriented databases can help researchers determine the effectiveness of alternative treatment methods and monitor outcomes (Fahrenholz 2017c, 128).

Data content standards are used to:

Share data in the same way the users interpret data Data standards allow us to share data in a uniform way. Data standards include data content standards and data exchange standards. Data content standards are clear guidelines for the acceptable values for specified data fields. The use of data content standards make it possible to share information so that users are able to interpret data in the same way (Sayles and Kavanaugh-Burke 2018, 31).

The purpose of the data dictionary is to ________ definitions and ensure consistency of use.

Standardize The purpose of the data dictionary is to standardize definitions and ensure consistency of use. Standardizing data enhances use across systems. Communication is improved in clinical treatment, research, and business processes through a common understanding of terms (Sayles and Kavanaugh-Burke 2018, 30).

Jane Smith emailed her physician, Dr. Ward, to express concern about an abnormal lab value report she received during her last physical exam. Dr. Ward responded to Jane's email by further explaining the lab test and value meanings and then offered various treatment options. How should this email correspondence be handled?

Since this email correspondence relates to communication between a physician and a patient and includes PHI, the facility should include the email in the patient's medical record. Facilities should maintain all information related to patient diagnosis and treatment methods in the patient record. Only information related to appointment timeframes and insurance and billing correspondence should not be made part of the record (Reynolds and Morey 2020, 118).

The distribution in this curve is:

Skewed right Skewness is the horizontal stretching of a frequency distribution to one side or the other so that one tail is longer than the other. The direction of skewness is on the side of the long tail. Thus, if the longer tail is on the right, the curve is skewed to the right. If the longer tail is on the left, the curve is skewed to the left (White 2020a, 186, 290).

Data mapping is used to harmonize data sets or code sets. The code or data set from which the map originates is the:

Source For the purposes of mapping, the term coding system is used very broadly to include classification, terminology, and other data representation systems. Mapping is necessary as health information systems and their use evolves in order to link disparate systems and data sets. Any data map will include a source and a target. The source is the code or data set from which the map originates (Biedermann and Dolezel 2017, 155).

Bloodwork results from the laboratory information system, mammogram reports and films from the radiology information system, and a listing of chemotherapy agents administered to the patient from the pharmacy information system are all delivered into the patient's EHR. These different information systems that feed information into the EHR are known as:

Source systems Source systems are information systems that capture and feed data into the EHR. Source systems include the electronic medication administration record (EMAR), laboratory information system, radiology information system, hospital information system, nursing information systems, and more (Sayles and Kavanaugh-Burke 2018, 146).

Derek, an HIM technician, reviews each record in the EHR system upon discharge of the patient to ensure that the system correctly assigned all documentation to the correct tab category (for example, all lab reports under the lab tab and x-ray reports under the radiology tab). This system utilizes which format for its patient care record?

Source-oriented A source-oriented format is when information is categorized according to its supplier or source (in the case of a hospital, this could be by department) (Reynolds and Morey 2020, 121).

The data in the following graph illustrate changes in a hospital's profile. What concerns might the hospital's quality council need to address based on these changes in their customer base?

Staffing changes might be necessary to accommodate patients who have cultural differences. The graph shows that the Asian population has increased in the last five years, so the organization may need to adjust staffing, offer a wider variety in dietary choices, and ensure patient rights and safety are appropriate in the face of possible language barriers and cultural differences (Shaw and Carter 2019, 90).

One of benefits of this type of data entry is that it is easy to determine if the data are complete.

Structured data Structured data can have many benefits include completeness, quality, and accessibility of the data for a variety of purposes. Structured data are often entirely appropriate and highly recommended for data entry when the options are limited or are required to conform to a specific standard (Biedermann and Dolezel 2017, 159).

A data element such as "date of birth" in a database is considered which of the following?

Structured data Structured data commonly refer to data that are organized and easily retrievable and interpreted by traditional databases and data models (Johns 2020, 83).

The data elements in a patient's automated laboratory result are examples of:

Structured data Structured data commonly refer to data that are organized and easy to retrieve and to interpret by traditional databases and data models. The data elements in a patient's automated laboratory order, or result, are coded and alphanumeric. Their fields are predefined and limited. In other words, the type of data is discrete, and the format of this data is structured (Johns 2020, 83).

If an analyst is studying the wait times at a clinic and the only list of patients available is on hard copy, which sampling technique is the easiest to use?

Systematic sampling A systematic random sample is a simple random sample that may be generated by selecting every fifth or every tenth member of the sampling frame. In order to ensure that a systematic random sample is truly random, the sample frame should not be sorted in an order that might bias the sample (White 2016a, 140).

When an entity relational diagram is implemented as a relational database, an entity will become a(n):

Table An entity becomes a table in your relational database because it is the person, place, or thing about which you are collecting the data in your database. You would need to be able to query data on each entity from the database (White 2016a, 46).

The HIM director at Community Hospital has noticed that history and physicals and operative reports are not being transcribed and returned by the transcription service within the negotiated timeframes. What should be her primary concern related to this issue?

That the Joint Commission will find that history and physicals are not being uploaded to the EHR system within the required 24-hour timeframe The Joint Commission requires that history and physicals be on patient charts within 24 hours of admission or before a surgical procedure. The turnaround time for the transcription service is problematic as the documentation is not in the record within the timeframe regulated by the Joint Commission (Reynolds and Morey 2020, 124).

The name of the government agency that has led the development of basic data sets for health records and computer databases is:

The National Committee on Vital and Health Statistics The National Committee on Vital and Health Statistics (NCVHS) has developed the initial efforts toward creating standardized data sets for use in different types of healthcare settings, including acute care, ambulatory care, long-term care, and home care (Fahrenholz 2017a, 62).

An analyst wishes to test the hypothesis that the wait time in the emergency department is longer on weekends than weekdays. What is the alternative hypothesis?

The average wait time is longer on weekends. The alternative hypothesis is the compliment of the null hypothesis and typically requires some action to be taken. In this scenario, the analyst is comparing emergency department wait times between weekends and weekdays. The alternative hypothesis would be that the average wait time is longer on weekends (White 2016a, 65).

Who owns the health records of patients treated in a healthcare facility?

The facility Health records and other documentation related to patient care are the property of the hospital or healthcare provider that created them. However, the information in each record belongs to the individual patient (Fahrenholz 2017a, 45).

Which of the following is an acceptable means of authenticating a record entry?

The physician personally signs the entry electronically. Authentication means to prove authorship and can be done in several ways. Methods of electronically signing documentation include a digital signature (a digitized image of a signature), a biometric identifier such as fingerprint or retinal scan, or a code or password. The physician assistant and charge nurse cannot authenticate the physician's entry in lieu of the physician as it is the physician's documentation. Likewise, having the HIM clerk use a physician's signature stamp is not an accepted method of authentication (Reynolds and Morey 2020, 126-127).

The following descriptors about the data element DISCHARGE_DATE are included in a data dictionary: definition: date patient was discharged from the hospital; data type: date; field length: 15; required field: yes; default value: none; template: none. For this data element, data integrity would be better assured if:

The template was defined A pattern used in computer-based patient records to capture data in a structured manner is called a template. One benefit of using a template is to ensure data integrity upon data entry (Sayles and Kavanaugh-Burke 2020, 16).

Which statement is true about the following figure?

There is a positive relationship between the variables. Scatter diagrams are used to plot the points for two continuous variables that may be related to each other in some way. Whenever a scatter diagram indicates that the points are moving together in one direction or another, conclusions about the variables' relationship, either positive or negative, become evident. In this case a positive relationship between the variables can be seen as the points gather together at the top of the diagram (Oachs 2020, 789).

What following materials are required elements in an emergency care record?

Time and means of the patient's arrival, treatment rendered, and instructions at discharge The content of the emergency health record should generally include the time and means of arrival, treatment rendered, and instructions at discharge. Facilities are required to do a pertinent history, including the chief complaint and onset of illness or injury but not a complete medical history of the patient (Reynolds and Morey 2020, 118-119).

Lisa, an HIM analyst for Healthwise Hospital, is conducting a quantitative analysis of a discharged patient's chart. Her goal in this process is:

To identify deficiencies in the chart early so they can be corrected Quantitative analysis is conducted to determine whether documentation is complete and accounted for in the medical record. If information is missing or incomplete, it is flagged for the provider to review and complete (Reynolds and Morey 2020, 125).

Jim was admitted for hip replacement surgery, and during his procedure he was administered blood products. Postoperatively, Jim developed a rash and fever. The presence of these symptoms will be investigated by the hospital as a possible:

Transfusion reaction The cause of every transfusion reaction, the signs, symptoms, or conditions suffered by a patient as the result of the administration of an incompatible transfusion, must be investigated. Most deaths resulting from hemolytic transfusion reactions were primarily attributable to incomplete patient identification processes for blood verification (Shaw and Carter 2019, 162).

The Abbreviated Injury Scale is a data element recorded in which of the following registries?

Trauma The Abbreviated Injury Scale reflects that nature of the injury and the severity (threat to life) by body system. It may be assigned manually by the registrar or generated as part of the database from data entered by the trauma registrar (Sharp and Madlock-Brown 2020, 182).

The statement "All patients admitted with a diagnosis falling into ICD-10-CM code numbers S00 through T88" represents a possible case definition for what type of registry?

Trauma registry In a trauma registry, the case definition might be all patients admitted with a diagnosis falling into ICD-10-CM code numbers S00-T88, the trauma diagnosis codes (Sharp and Madlock- Brown 2020, 181).

Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of patients to the acute-care hospital in which she works. What is the first resource she should use?

UHDDS In 1974, the federal government adopted the Uniform Hospital Discharge Data Set (UHDDS) as the standard for collecting data for the Medicare and Medicaid programs. When the Prospective Payment Act was enacted in 1983, UHDDS definitions were incorporated into the rules and regulations for implementing diagnosis-related groups (DRGs). A key component was the incorporation of the definitions of principal diagnosis, principal procedure, and other significant procedures, into the DRG algorithms (Amatayakul 2017, 301).

Which data set would be used to document an elective surgical procedure that does not require an overnight hospital stay?

Uniform Ambulatory Care Data Set The Uniform Ambulatory Care Data Set (UACDS) is a data set developed by NCVHS consisting of a minimum set of patient-specific or client-specific elements to be collected in ambulatory care settings. The purpose of the UACDS is to collect and report standardized ambulatory data (Johns 2015, 280).

The inpatient data set incorporated into federal law and required for Medicare reporting is the:

Uniform Hospital Discharge Data Set Medicare requires that all inpatient hospitals collect a minimum set of patient-specific data elements, which are in databases formulated from hospital discharge abstract systems. The patient-specific data elements are referred to as the Uniform Hospital Discharge Data Set (UHDDS) (Schraffenberger and Palkie 2020, 91-92).

What type of information makes it easy for hospitals to compare and combine the contents of multiple patient health records?

Uniform data sets A data set is defined as a list of recommended data elements with uniform definitions that are relevant for a particular use. Data sets are used to encourage uniform data collection and reporting (Johns 2015, 277).

Dr. Collins admitted Mr. Smith to University Hospital. Blue Cross Insurance will pay Mr. Smith's hospital bill. Upon discharge from the hospital, who owns the health record of Mr. Smith?

University Hospital Although registries and databases are almost universally computerized, data collection is sometimes done manually. The most frequent method is abstracting, the process of reviewing the patient health records and entering the required data elements into the database (Sharp and Madlock-Brown 2020, 197).

Notes written by physicians and other practitioners as well as dictated and transcribed reports are examples of:

Unstructured clinical information The clinical documentation that is entered into the patient record as text is not as easily automated due to the unstructured nature of the information. Unstructured clinical information includes notes written by physicians and other practitioners who treat the patient, dictated and transcribed reports, and legal forms such as consents and advance directives (Biedermann and Dolezel 2017, 84).

Ensuring that only the most recent report is available for viewing is known as:

Version control Version control in healthcare is the process whereby a healthcare facility ensures that only the most current version of a patient's health record is available for viewing, updating, and so forth. However, there must be a way for authorized users to be able to view the previous version to see what was changed (Sayles and Kavanaugh-Burke 2018, 23).

Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallux valgus) is one purpose of:

Vocabulary standards A vocabulary standard is a common definition for medical terms to encourage consistent descriptions of an individual's condition in the health record (Sayles and Kavanaugh-Burke 2018, 207).

Under which circumstances may an updated entry be added to a patient's health record in place of a complete history and physical?

When the patient is readmitted within 30 days of the initial treatment for the same condition An updated entry may be used for the patient's history and physical when the patient is readmitted within 30 days of the initial treatment for the same condition (Reynolds and Morey 2020, 110).

The health information management (HIM) manager is concerned with a backlog in transcription of surgical reports. The medical staff rules and regulations stipulate that the surgeon should:

Write a detailed postoperative progress note about the procedure performed The operative report should be written or dictated immediately after surgery and filed in the patient's health record as soon as possible. Some hospitals may require surgeons to include brief descriptions of the operations in their postoperative progress notes when delays in dictation or transcription are unavoidable. Other caregivers can then refer to the progress note until the final operative report becomes available (Reynolds and Morey 2020, 115).