Domain 1
Which of the following plans address how information can be documented in the health record during down time or a catastrophic event? a. Disaster b. E-discovery response c. Business continuity d. Emergency documentation
A. 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
What term is used in reference to the systematic review of sample health records to determine whether documentation standards are being met? a. Qualitative analysis b. Legal record review c. Utilization analysis d. Ongoing record review
A. Qualitative analysis is a review of the health record to ensure the adequacy of entries documenting the quality of care are present
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: a. Minimum data set to plan her care
A.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
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: a. Patient identification and demographic accuracy b. Authorship integrity c. Documentation integrity d. Auditing integrity
C. 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
Ensuring that only the most recent report is available for viewing is known as: a. Documentation integrity b. Authorship c. Validation d. Version control
D. 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
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: a. Healthcare-associated infection b. Hospital sickness c. Community-acquired infection d. Community sickness
a 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
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: a. The template was defined b. The data type was numeric c. The field was not required d. The field length was longer
a 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
The basic component of a(n) ________ is an object that contains both data and their relationships in a single structure. a. Object-oriented database b. Relational database c. Access database d. Structured database
a 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
Reviewing a health record for authentication and medical reports is called: a. Analysis b. Coding c. Assembly d. Indexing
a 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
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? a. Authorship b. Validation c. Integrity d. Identification
a 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
A patient born with a neural tube defect would be included in which type of registry? a. Birth defects b. Cancer c. Diabetes d. Trauma
a 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
Which of the following are considered dimensions of data quality? a. Relevancy, granularity, timeliness, currency, accuracy, precision, and consistency b. Relevancy, granularity, timeliness, currency, atomic, precision, and consistency c. Relevancy, granularity, timeliness, concurrent, atomic, precision, and consistency d. Relevancy, granularity, equality, currency, precision, accuracy, and consistency
a Common characteristics of data quality are relevancy, granularity, timeliness, currency, accuracy, precision, and consistency
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? a. 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 b. By indicating to physicians what documentation must be completed once the patient goes home c. By giving the billing department a list of all the charges to date for the patient d. By allowing the documentation to be uploaded to the patient portal for the patient to use after discharge
a Concurrent record reviews help to catch incomplete documentation or unsigned orders while the patient is still in-house
Which of the following data sets would be most useful in developing a matrix for identification of components of the legal health record? a. Document name, media type, source system, electronic storage start date, stop printing start date b. Document name, media type c. Document name, medical record number, source system d. Document name, source system
a 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
Data content standards are used to: a. Share data in the same way the users interpret data b. Share data is a unique way c. Share data between disparate systems d. Modify data
a 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
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? a. Direct observation b. Interview c. Survey d. Work imaging
a 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
What is a primary purpose for documenting and maintaining health records? a. Effective communication among caregivers for continuity of care b. Substantiate claims for reimbursement c. Provide evidence for malpractice lawsuits d. Contribute to medical science
a 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
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? a. UHDDS b. UACDS c. MDS d. ORYX
a 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
Which of the following would not be an appropriate duty for an HIM professional? a. Documenting additions or deletions in a patient's record b. Monitoring documentation guidelines as set forth in legislation or regulatory standards c. Training care providers in documentation techniques d. Auditing patient records to determine the quality of the documentation
a 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
Danny, an HIM analyst for Memorial Hospital, is conducting a qualitative analysis of a discharged patient's chart. His goal in this process is: a. Determining if the documentation includes all requirements set by CMS, the state, and accrediting bodies b. Identifying whether all lab orders have corresponding lab reports in the chart c. Verifying that health professionals are providing appropriate care d. Ensuring the hospital bill is correct
a 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
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: a. Maintenance plan b. Management plan c. Attribute plan d. Strategic plan
a 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
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): a. Secondary data source b. Reliable data source c. Primary data source d. Unreliable data source
a 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
Which of the following is a concept designed to help standardize clinical content for sharing between providers? a. Continuity of care record b. Interoperability c. Personal health record d. SNOMED
a 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
To ensure authentication of data entries, which type of signature is the most secure? a. Digital b. Electronic c. Handwritten d. Virtual
a 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
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? a. Physician b. Master patient c. Procedure d. Disease and operation
a 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
The first deliverable from a legal health record (LHR) definition project is a: a. List of LHR stakeholders b. Document matrix of LHR components c. Letter of support from management d. Master source system matrix
a 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
How do healthcare providers use the administrative data they collect? a. For regulatory, operational, and financial purposes b. For statistical data purposes c. For electronic health record tracking purposes d. For continuity of patient care purposes
a 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 patient-identifiable data that are used in the healthcare organization. Administrative data are patient-identifiable data used for administrative, regulatory, healthcare operation, and payment
A collection of data that is organized so its contents can be easily accessed, managed, and updated is called a: a. Spreadsheet b. Database c. File d. Data table
b 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
A method that has been developed for presenting a variety of data on a single display in an easy-to-read format is called a: a. Graph b. Dashboard c. Table d. Data visualization
b A method that has been developed for presenting a variety of data on a single display in an easy-to-read format is called a dashboard
A nurse tried to enter a temperature of 134 degrees and the system would not accept it. What is this an example of? a. Data collection b. Edit check c. Data reliability d. Hot spot
b 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
Which of the following personnel should be authorized, per hospital policy, to take a physician's verbal order for the administration of medication? a. Unit secretary working on the unit where the patient is located b. Nurse working on the unit where the patient is located c. Health information director d. Admissions registrars
b 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
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)? a. Face sheet b. Care plan c. Diagnosis plan d. Flow sheet
b Care plans are required documentation in a long-term care hospital (LTCH). Some LTCHs may use critical paths (or clinical pathways) for specific patients
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
b 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
Records that are not completed by the physician within the time frame specified in the healthcare organization policies are called: a. Default records b. Delinquent records c. Loose records d. Suspended records
b 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
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? a. Core measure b. Resident Assessment Instrument c. Precertification d. Record of transfer
b Every long-term care facility must complete a comprehensive assessment of every resident's needs by using the resident assessment instrument (RAI)
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: a. Auto-authentication fields b. Metadata c. Data d. Information fields
b 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
Personal information about patients such as their names, ages, and addresses is considered what type of information? a. Clinical b. Administrative c. Operational d. Accreditation
b 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
The inpatient data set incorporated into federal law and required for Medicare reporting is the: a. Ambulatory Care Data Set b. Uniform Hospital Discharge Data Set c. Minimum Data Set for Long-term Care d. Health Plan Employer Data and Information Set
b 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
An alteration of the health information by modification, correction, addition, or deletion is known as a(n): a. Change b. Amendment c. Copy and paste d. Deletion
b 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
Which of the following is the goal of quantitative analysis performed by health information management (HIM) professionals? a. Ensuring the record is legible b. Identifying deficiencies early so they can be corrected c. Verifying that health professionals are providing appropriate care d. Checking to ensure bills are correct
b 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
Lisa, an HIM analyst for Healthwise Hospital, is conducting a quantitative analysis of a discharged patient's chart. Her goal in this process is: a. To ensure that the record is legible b. To identify deficiencies in the chart early so they can be corrected c. To verify that health professionals are providing appropriate care d. To ensure that the hospital bill is correct
b 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
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: a. Interoperability b. Source systems c. Continuity of care records d. Clinical decision support systems
b 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
The name of the government agency that has led the development of basic data sets for health records and computer databases is: a. The Centers for Medicare and Medicaid Services b. The National Committee on Vital and Health Statistics c. The American National Standards Institute d. The National Institute of Health
b 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
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? a. The average wait time is shorter on weekends. b. The average wait time is longer on weekends. c. The average wait time is different on weekends and weekdays. d. The average wait time is the same on weekends and weekdays.
b 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
Which of the following is a component of the resident assessment instrument? a. The resident's health record b. A standard Minimum Data Set (MDS) c. Preadmission Screening Assessment d. Annual Resident Review
b 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
The data that describe other data in order to facilitate data quality are found in the: a. Data definition language b. Data dictionary c. Data standards d. Data definition
b 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
Which of the following represents dataflow for a hospital inpatient admission? a. Registration > diagnostic and procedure codes assigned > services performed > charges recorded b. Registration > services performed > charges recorded > diagnostic and procedure codes assigned c. Services performed > charges recorded > registration > diagnostic and procedure codes assigned d. Diagnostic and procedure codes assigned > registration > services performed > charges recorded
b 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
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? a. One-to-one b. One-to-many c. Many-to-many d. One-to-two
b 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
Identify the level in the data model that describes how the data is stored within the database: a. Conceptual data model b. Physical data model c. Logical data model d. Data manipulation language
b 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
The purpose of the data dictionary is to ________ definitions and ensure consistency of use. a. Identify b. Standardize c. Create d. Organize
b 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
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: a. Nominal, ordinal, interval, ratio b. Nominal, ratio, ordinal, ordinal c. Ordinal, nominal, ratio, interval d. Ratio, ordinal, interval, nominal
b 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
Which of the following is not associated with a typical data dictionary? a. Table names b. An entity-relationship diagram c. A description of each attribute d. Whether the attribute is required
b Though data dictionaries can be part of the database design process, they do not include entity-relationship diagrams. Data dictionaries typically have certain types of data and the standards are important to follow
Unstructured data may be preferred over structured data because: a. It does not require processing b. It provides greater detail c. Clinicians know how to enter it d. It is more complete
b 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
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: a. Mean b. Noncompliant and hostile toward staff c. Belligerent and out of line d. A pain in the neck
b 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
It is important for a healthcare entity to have ________ addressing how to deal with corrections made to erroneous entries in health records. a. Training sessions b. Policies and procedures c. Verbally communicated instructions d. A supervisory committee
b 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
According to the UHDDS definition, ethnicity should be recorded on a patient record as: a. Race of mother b. Race of father c. Hispanic, non-Hispanic d. Free-text descriptor as reported by patient
c 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
Which of the following is a graphical display of the relationships between tables in a database? a. RDMS b. SQL c. ERD d. SAS
c 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
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? a. Predictive modelling b. Indirect standardization c. Real-time analytics d. Data mining
c 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
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? a. CPOE b. OCR c. Backscanning d. Barcoding
c 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
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? a. Physician progress notes and medication record b. Nursing and physician progress notes c. Medication administration record and clinical laboratory reports d. Physician orders and clinical laboratory reports
c 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
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? a. Slope of the linear regression time b. T-test c. Correlation d. Intercept of the linear regression line
c Correlation is a statistic that is used to describe the association or relationship between two variables
Records consisting of multiple electronic systems that do not communicate or are not logically architected for record management are called: a. Electronic medical records b. Electronic health records c. Hybrid health records d. Computerized health records
c 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
A pediatrician would report the fact that he or she administered the MMR vaccine to a toddler on a(n): a. Diabetes registry b. Cancer registry c. Immunization registry d. Trauma registry
c 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
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? a. DNFB cases met the benchmark 100 percent of the time. b. DNFB cases met the benchmark 75 percent of the time. c. DNFB cases met the benchmark 50 percent of the time. d. DNFB cases met the benchmark 25 percent of the time.
c In this example, DNFB met the benchmark in January, February, and June, which is 3/6 or 50 percent of the time
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: a. Information asset management b. Information management c. Information governance d. Enterprise information management
c 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
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? a. That the transcription service company will overcharge the hospital for reports that are delayed b. That physicians will stop dictating reports and just include comments in the progress notes c. That the Joint Commission will find that history and physicals are not being uploaded to the EHR system within the required 24-hour timeframe
c 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
In long-term care, the resident's comprehensive assessment is based on data collected in the: a. UHDDS b. OASIS c. MDS d. HEDIS
c 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
Which data set would be used to document an elective surgical procedure that does not require an overnight hospital stay? a. Uniform Hospital Discharge Data Set (UHDD) b. Data Elements for Emergency Department Systems (DEEDS) c. Uniform Ambulatory Care Data Set (UACD) d. Essential Medical Data Set (EMDS)
c 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
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? a. Clinical data b. Statistical data c. Secondary data d. Primary data
c The claims data is secondary data, that is, the data are used for a purpose that was not the primary reason for collection
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: a. Secondary data source b. Aggregate data source c. Primary data source d. Reliable data source
c 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
Who is responsible for ensuring the quality of health record documentation? a. Board of directors b. Administrator c. Provider d. Health information management professional
c The provider is responsible for ensuring the quality of the documentation of the healthcare record
This functionality can result in confusion from incessant repetition of irrelevant clinical data. a. Change b. Amendment c. Copy and paste d. Deletion
c 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
What type of report would give administrators structured information in a variety of graphs to better plan facility operations? a. Enterprise master patient index b. Integrated delivery system c. Registration—admissions, discharge, transfer system d. Executive information system dashboard
d A dashboard report gives administration-structured information to make intelligent decisions for the future
A critical early step in designing an EHR in which the characteristics of each data element are defined is to develop a(n): a. Accreditation manual b. Core content c. Continuity of care record d. Data dictionary
d 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
Which of the following is an example of a 1:1 relationship? a. Patients to hospital admissions b. Patients to consulting physicians c. Patients to clinics d. Patients to hospital beds
d 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
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? a. Durable power of attorney b. Living consent form c. Informed consent d. Advance directive
d An advance directive is a written document that describes the patient's healthcare preferencesin 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
When an entity relational diagram is implemented as a relational database, an entity will become a(n): a. Query b. Form c. Object d. Table
d 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
The process of providing proof of the authorship of health record documentation is called: a. Identification b. Standardization of data capture c. Standardization of abbreviations d. Authentication
d 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
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? a. Process comparison b. Outcome comparison c. Comparing d. Benchmarking
d 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
Which of the following processes is an ancillary function of the health record? a. Admitting and registration information b. Billing and reimbursement c. Patient assessment and care planning d. Biomedical research
d Biomedical research is considered an ancillary function of the health record (
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: a. Have the administrator of the hospital complete them b. Have the charge nurse on the respective nursing units complete them c. Ask the chief of staff to complete them d. File the incomplete records with a notation about the physician's death
d 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
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? a. Birth defect registry b. Cancer registry c. Diabetes registry d. Trauma registry
d 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
Which statement is true about the following figure? a. There is no correlation between the variables. b. There is a negative relationship between the variables. c. There is a weak negative correlation between the variables. d. There is a positive relationship between the variables.
d 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
The distribution in this curve is: a. Normal b. Bimodal c. Skewed left d. Skewed right
d 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
While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on the: a. Reason for admission b. Activities of daily living c. Discharge diagnosis d. Reason for encounter
d 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
The practices or methods that defend against charges questioning the integrity of the data and documents are called: a. Authentication b. Security c. Accuracy d. Nonrepudiation
d 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
