HIM 410: Module 1: Health Data Content and Standards

Many of the principles of forms design apply to both paper-based and computer-based systems. For example, the physical layout of the form and/or screen should be organized to match the way the information is requested. Facilities that are scanning and imaging paper records as part of a computer-based system must give careful consideration to use of box design. signature line for authentication. bar code placement. placement of hospital logo.

bar code placement. Most facilities use bar-coded patient identification to ensure proper indexing into the imaging system.

Documentation found in acute care health records should include core measure quality indicators required for compliance with Medicare's Health Care Quality Improvement Program (HCQIP). A typical quality indicator for patients with pneumonia might be beta blocker at discharge. discharged on antithrombotic. blood culture before first antibiotic received. early administration of aspirin.

blood culture before first antibiotic received. "Beta blocker at discharge" and "early administration of aspirin" represent typical quality indicators for patients with acute myocardial infarction; "discharged on antithrombotic" represents a quality indicator typical for stroke patients. The correct answer is "blood culture before first antibiotic received" since this is the only clinical indicator that applies directly to pneumonia patients.

Using a template to collect data for key reports may help to prompt caregivers to document all required data elements in the patient record. This practice contributes to data security. comprehensiveness. timeliness. accuracy.

comprehensiveness. Data comprehensiveness refers specifically to the presence of all required data elements.

In your acute care facility it has become critical that up-to-date information regarding patients who are transferred to the oncology patient care unit be immediately sent to an outpatient scheduling system to facilitate outpatient appointments. This transfer of service can be obtained most readily from the R-ADT system. the indicator monitoring program. generic screens used by record abstractors. the disease index.

the R-ADT system. For tracking in-house patients who have been transferred to a specialty unit, the best source of information is the registration-admission, discharge, and transfer system.

You have been appointed as chair of the Health Record Committee at a new hospital. Your committee has been asked to recommend time-limited documentation standards for inclusion in the medical staff bylaws, rules, and regulations. The committee documentation standards must meet the standards of both the Joint Commission and the Medicare Conditions of Participation. The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report should be set at 24 hours after admission or prior to surgery. 12 hours after admission or prior to surgery. 24 hours after admission. 12 hours after admission.

24 hours after admission or prior to surgery. This time requirement complies with both Joint Commission and COP standards.

A data item to include on a qualitative review checklist of newborn inpatient health records that need NOT be included on adult records would be time and means of arrival. APGAR score. chief complaint. condition on discharge.

APGAR score. "Chief complaint" and "time and means of arrival" are items that should be documented on any inpatient record. "Condition on discharge" reflects a data item you would expect to find on ER records. APGAR scores are part of newborn documentation.

The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely include checking for documentation regarding a) whether the severity of illness and/or intensity of service warranted acute level care. b) the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed. c) whether a postoperative infection occurred and how it was treated. d) the quality of follow-up care.

B) the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed. "Whether a postoperative infection occurred and how it was treated" represents an appropriate job for the infection control officer. "The quality of follow-up care" represents the clinical care evaluation process, rather than the review of quality documentation. "Whether the severity of illness and/or intensity of service warranted acute level care" is a function of the utilization review program. The correct answer is "the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed."

Select the appropriate situation for which a final progress note may legitimately be substituted for a discharge summary in an inpatient medical record. Baby Boy Hiltz's mother admitted 1/5/2018, C-section delivery, and discharged 1/7/2018. Baby Boy Doe admitted 1/3/2018, died 1/4/2018. Patient admitted with COPD 1/4/2018 and discharged 1/7/2018. Baby Boy Hiltz, born 1/5/2018, maintained normal status, discharged 1/7/2018.

Baby Boy Hiltz, born 1/5/2018, maintained normal status, discharged 1/7/2018. A final progress note may substitute for a discharge summary in the following cases: patients who are hospitalized less than 48 hours with problems of a minor nature, normal newborns, and uncomplicated obstetrical deliveries. "Patient admitted with COPD 1/4/2018 and discharged 1/7/2018" does not qualify because of the nature of the problem and the length of stay. "Baby Boy Hiltz's mother admitted 1/5/2018, C-section delivery, and discharged 1/7/2018" describes a complicated delivery, and "Baby Boy Doe admitted 1/3/2018, died 1/4/2018" cites a severely ill patient rather than one with a minor problem.

The best resource for checking out specific voluntary accreditation standards and guidelines for a rehabilitation facility is the CARF manual. Conditions of Participation for Rehabilitation Facilities. Joint Commission manual. Medical Staff Bylaws, Rules, and Regulations.

CARF manual. The manual published by the Commission on Accreditation of Rehabilitation Facilities will have the most specific and comprehensive standards for a rehabilitation facility.

One of the Joint Commission National Patient Safety Goals (NSPGs) requires that health care organizations eliminate wrong-site, wrong-patient, and wrong-procedure surgery. In order to accomplish this, which of the following would NOT be considered part of a preoperative verification process? Confirm the patient's true identity. Mark the surgical site. Follow the daily surgical patient listing for the surgery suite if the patient has been sedated. Review the medical records and/or imaging studies.

Follow the daily surgical patient listing for the surgery suite if the patient has been sedated. "Confirm the patient's true identity," "mark the surgical site," and "review the medical records and/or imaging studies"—these are usually in the protocol to prevent wrong site, wrong patient, or wrong surgery. The correct answer is following the daily surgical patient listing—that choice would NOT be an appropriate step in making sure you have the correct identity of the patient, the correct site, or the correct surgery.

As the compliance officer for a large physician practice group, you are interested in researching the original requirements for meaningful use of certified EHRs for use in an upcoming presentation. You begin by googling Health Care Quality Improvement Act. HIPAA. HITECH Act. EMTALA.

HITECH Act. The HITECH Act was signed into law in 2009 to promote the adoption and meaningful use of EHRs and health information technology.

In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each SNF resident as defined in the MDS. UHDDS. Uniform Ambulatory Core Data. Uniform Clinical Data Set.

MDS. OBRA mandates comprehensive functional assessments of long-term care residents using the Minimum Data Set (MDS) for Long-Term Care.

Currently, the enforcement of HIPAA Privacy and Security Rules is the responsibility of the Department of Recovery Audit Coordinators. Office of Inspector General. Office for Civil Rights. FBI.

Office for Civil Rights. The Office for Civil Rights (OCR) ensures equal access to certain health and human services and protects the privacy and security of health information.

Which of the following is a form or view that is typically seen in the health record of a long-term care patient but is rarely seen in records of acute care patients? emergency record medical consultation pharmacy consultation physical exam

Pharmacy Consultation Pharmacy consults are required for elderly patients who typically take multiple medications. These consults review for potential drug interactions and/or discrepancies in medications given and those ordered.

Gerda Smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. According to her sister, Gerda has had a recent medical history taken at the public health department. The physician on call is grateful that she can access this patient information using the area's expert system. RHIO. CPOE. EDMS system.

RHIO. With the increasing number of health care entities implementing EHR systems, the networking of electronic information between facilities has become a reality in some areas due to the establishment of regional health information organizations. EDMS = electronic data management system. CPOE = computerized provider order entry system

As supervisor of the cancer registry, you report the registry's annual caseload to administration. The most efficient way to retrieve this information would be to use patient abstracts. patient index. follow-up files. accession register.

accession register. The accession register is a permanent log of all the cases entered into the database. Each number assigned is preceded by the accession year, making it easy to assess annual workloads.

For inpatients, the first data item collected of a clinical nature is usually review of systems. expected payer. admitting diagnosis. principal diagnosis.

admitting diagnosis. Clinical data include all health care information collected during a patient's episode of care. During the registration or intake process, the admitting diagnosis, provided by the attending physician, is entered on the face sheet. If the patient is admitted through the ED, the chief complaint listed on the ED record is usually the first clinical data collected. The principal diagnosis is often not known until after diagnostic tests are conducted. Demographic data are not clinical in nature. The review of systems is collected during the history and physical, which is typically done after admission to the hospital.

In addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain standing orders. discharge order. stop orders. telephone orders.

discharge order. Although many patient health records may feasibly contain all of the orders listed, only the discharge order is required to document the formal release of a patient from the facility. Absence of a discharge order would indicate that the patient left against medical advice and this event should be thoroughly documented as well.

Based on the following documentation in an acute care record, where would you expect this excerpt to appear? Initially the patient was admitted to the medical unit to evaluate the x-ray findings and the rub. He was started on Levaquin 500 mg initially and then 250 mg daily. The patient was hydrated with IV fluids and remained afebrile. Serial cardiac enzymes were done. The rub, chest pain, and shortness of breath resolved. EKGs remained unchanged. Patient will be discharged and followed as an outpatient. physical exam clinical laboratory report admission note discharge summary

discharge summary The excerpt clearly indicates an overall summary of the patient's course in the hospital, which is a common element of the discharge summary.

Which of the following is least likely to be identified by a retrospective quantitative analysis of a health record? X-ray report charted on the wrong record missing discharge summary need for physician authentication of two verbal orders discrepancy between postoperative diagnosis by the surgeon and pathology diagnosis by the pathologist

discrepancy between postoperative diagnosis by the surgeon and pathology diagnosis by the pathologist "Missing discharge summary," "need for physician authentication of two verbal orders," and "X-ray report charted on the wrong record" all represent common checks performed by a quantitative analysis clerk: missing reports, signatures, or patient identification. "Discrepancy between postoperative diagnosis by the surgeon and pathology diagnosis by the pathologist" represents a more in-depth review dealing with the quality of the data documented.

Which of the following is a secondary data source that would be used to quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months? disease index patient register procedure index pediatric census sheet

disease index The disease index is a listing of diagnosis code numbers that matches the codes to the patients who had those diseases.

You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility's physicians' index. number control index. patient index. disease index.

disease index. The major sources of case findings for cancer registry programs are the pathology department, the disease index, and the logs of patients treated in radiology and other outpatient departments. The number index identifies new health record numbers and the patients to whom they were assigned. The physicians' index identifies all patients treated by each doctor. The patient index links each patient treated in a facility with the health number under which the clinical information can be located.

A major contribution to a successful CDI program is the ability of the CDI specialist to demonstrate to the medical staff as well as to administration the powerful impact that precise documentation has on the internal and external data reporting. In this role, he/she is acting as a(n) ambassador. reviewer. educator. manager.

educator. The CDI professional may act as a reviewer and manager, but the duties described are most representative of his/her role as an educator.

Joint Commission does not approve auto authentication of entries in a health record. The primary objection to this practice is that electronic signatures are not acceptable in every state. tampering too often occurs with this method of authentication. evidence cannot be provided that the physician actually reviewed and approved each report. it is too easy to delegate use of computer passwords.

evidence cannot be provided that the physician actually reviewed and approved each report. Auto authentication is a policy adopted by some facilities that allow physicians to state in advance that transcribed reports should automatically be considered approved and signed (or authenticated) when the physician fails to make corrections within a preestablished time frame (e.g., "Consider it signed if I do not make changes within 7 days."). Another version of this practice is when physicians authorize the HIM department to send weekly lists of unsigned documents. The physician then signs the list in lieu of signing each individual report. Neither practice ensures that the physician has reviewed and approved each report individually.

As the chair of a Forms Review Committee, you need to track the field name of a particular data field and the security levels applicable to that field. Your best source for this information would be the UHDDS. facility's data dictionary. glossary of health care terms. MDS.

facility's data dictionary. "MDS" and "UHDDS" are types of data sets for collecting data in long-term (MDS) and acute care (UHDDS) facilities. A data dictionary should include security levels for each field as well as definitions for all entities.

In the computerization of forms, good screen-view design, along with the options of alerts and alarms, makes it easier to ensure that all essential data items have been captured. One essential item to be captured on the physical exam is the family history as related by the patient. general appearance as assessed by the physician. chief complaint. subjective review of systems.

general appearance as assessed by the physician. The medical history (including chief complaint, history of present illness, past medical history, personal history, family history, and a review of systems) is provided by the patient or the most knowledgeable available source. The physical examination adds objective data to the subjective data provided by the patient. This exam begins with the physician's objective assessment of the patient's general condition.

An example of a primary data source for health care statistics is the MPI. accession register. disease index. health record.

health record. "Disease index," "accession register," and "MPI" are examples of secondary data sources. The health record is a primary source of data.

As a new HIM manager of an acute care facility, you have been asked to update the facility's policy for a physician's verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualifications of those individuals in your facility who have been authorized to record verbal orders. For this information, you will consult the policy and procedure manual. Federal Register. consolidated manual for hospitals. hospital bylaws, rules, and regulations.

hospital bylaws, rules, and regulations. Although Joint Commission, CMS, and state laws may include standards for verbal orders, the specific information regarding which employees have been given authority to transcribe verbal orders in your facility should be located in your hospital's bylaws, rules, and regulations.

The foundation for communicating all patient care goals in long-term care settings is the legal assessment. cognitive assessment. interdisciplinary plan of care. Uniform Hospital Discharge Data Set.

interdisciplinary plan of care. Unlike the acute care hospital, where most health care practitioners document separately, the patient care plan is the foundation around which patient care is organized in long-term care facilities because it contains the unique perspective of each discipline involved.

As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity and to confirm that necessary documents such as X-rays or medical records are available. They must also develop and use a process for apprising the patient of all complications that might occur. marking the surgical site. including the surgeon in the preanesthesia assessment. including the primary caregiver in surgery consults.

marking the surgical site. The Joint Commission requires hospitals to mark the correct surgical site and to involve the patient in the marking process to help eliminate wrong site surgeries.

In preparation for an upcoming site visit by Joint Commission, you discover that the number of delinquent records for the preceding month exceeded 50% of discharged patients. Even more alarming was the pattern you noticed in the type of delinquencies. Which of the following represents the most serious pattern of delinquencies? Fifteen percent of delinquent records show missing operative reports. missing discharge summaries. missing signatures on progress notes. absence of SOAP format in progress notes.

missing operative reports. "Missing signatures on progress notes" and "missing discharge summaries"—both signature omissions and discharge summary reports can be captured after discharge, but history and physicals should be on the chart within 24 hours of the patient's admission. The SOAP format is not a requirement of Joint Commission. Institutions are given a Type I recommendation when 2% of delinquent records are due to missing history and physicals or operative reports.

In creating a new form or computer view, the designer should be most driven by medical staff bylaws. flow of data on the page or screen. needs of the users. QIO standards.

needs of the users. The needs of the user are the primary concern in forms design.

A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the history and physical is true in this situation? Completion and charting of the H&P indicates compliance with Joint Commission standards for nonsurgical patients. noncompliance with Joint Commission standards. compliance with Joint Commission standards. compliance with Medicare regulations.

noncompliance with Joint Commission standards. Joint Commission specifies that H&Ps must be completed within 24 hours or prior to surgery.

The best example of point-of-care service and documentation is using an automated tracking system to locate a record. using occurrence screens to identify adverse events. doctors using voice recognition systems to dictate radiology reports. nurses using bedside terminals to record vital signs.

nurses using bedside terminals to record vital signs. Of the processes listed, only "nurses using bedside terminals to record vital signs" pertains to the clinical application of data entry into the patient's record at the time and location of service.

One record documentation requirement shared by both acute care and emergency departments is problem list. time and means of arrival. patient's condition on discharge. advance directive.

patient's condition on discharge. Time and means of arrival is required on ED records only. Evidence of known advance directive is required on inpatient records only. Problem list is typically required on ambulatory records only. The correct answer is "patient's condition on discharge," which should be recorded on both ED and acute care records.

Based on the following documentation in an acute care record, where would you expect this excerpt to appear? The patient is alert and in no acute distress. Initial vital signs: T 98, P 102 and regular, R 20 and BP 120/69... past medical history physical exam social history chief complaint

physical exam "Past medical history," "social history," and "chief complaint" represent components of the medical history as supplied by the patient, while the physical exam is an entry obtained through objective observation and measurement made by the provider.

Setting up a drop-down menu to make sure that the registration clerk collects "gender" as "male, female, or unknown" is an example of ensuring data timeliness. validity. reliability. precision.

precision. Validity refers to the accuracy of data, while reliability refers to its consistency. Timeliness refers to data being available within a time frame helpful to the user, and data precision refers to data that is precise and collected in its exact form so there will be no variability in the data.

Which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record? progress notes database initial plan problem list

problem list In a POMR, the database contains the history and physical; the problem list includes titles, numbers, and dates of problems and serves as a table of contents of the record; the initial plan describes diagnostic, therapeutic, and patient education plans; and the progress notes document the progress of the patient throughout the episode of care, summarized in a discharge summary or transfer note at the end of the stay.

For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the transfer record. problem list. interdisciplinary patient care plan. discharge summary.

problem list. Patient care plans, pharmacy consultations, and transfer summaries are likely to be found on the records of long-term care patients.

During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day 4 of hospitalization, there was one missed dose of insulin. What type of review is this clerk performing? legal review utilization review quantitative review qualitative review

qualitative review Quantitative analysis involves checking for the presence or absence of necessary reports and/or signatures, while qualitative analysis may involve checking documentation consistency, such as comparing a patient's pharmacy drug profile with the medication administration record.

Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of legal analysis. quantitative review. qualitative review. peer review.

qualitative review. Peer review typically involves quality of care issues rather than quality of documentation issues. Legal analysis ensures that the record entries would be acceptable in a court of law. The correct choice is qualitative review.

As the coding supervisor, your job description includes working with agents who have been charged with detecting and correcting overpayments made to your hospital in the Medicare Fee for Service program. You will need to develop a professional relationship with QIO physicians. the OIG. recovery audit contractors. MEDPAR representatives.

recovery audit contractors. The correct answer is "recovery audit contractors." The RAC program is mandated to find and correct improper Medicare payments paid to health care providers participating in the Medicare reimbursement program. OIG stands for Office of Inspector General; MEDPAR stands for Medicare Provider Analysis and Review; QIO stands for Quality Improvement Organization.

Though you work in an integrated delivery network, not all systems in your network communicate with one another. As you meet with your partner organizations, you begin to sell them on the concept of an important development intended to support the exchange of health information across the continuum within a geographical community. You are promoting that your organization join a continuum of care. data retrieval portal group. regional health information organization. data warehouse.

regional health information organization. Regional health information organizations are intended to support health information exchange within a geographic region.

The minimum length of time for retaining original medical records is primarily governed by Joint Commission. state law. readmission rates. medical staff.

state law. The statute of limitations for each state is information that is crucial in determining record retention schedules.

While data governance focuses primarily on managing data as it is being created within a healthcare system, information governance focuses instead on managing data currency the granularity of healthcare systems the output of those systems data accuracy

the output of those systems Data governance manages the information created in the different systems used in healthcare, while information governance manages the information output from those systems.

An effective information governance system should include all of the following principles except one: the principle of disposition the principle of retention the principle of interoperability the principle of availability

the principle of interoperability The principles of retention, availability, and disposition are all important in supporting proper information governance across the organization. The principle of interoperability is more limited to the IT Department.

A primary focus of screen format design in a health record computer application should be to ensure that data fields can be randomly accessed. programmers develop standard screen formats for all hospitals. the user is capturing essential data elements. paper forms are easily converted to computer forms.

the user is capturing essential data elements. Both paper-based and computer-based records share similar design considerations. Among these are the selection and sequencing of essential data items.

A key data item you would expect to find recorded on an ER record but would probably NOT see in an acute care record is the instructions for follow-up care. physical findings. lab and diagnostic test results. time and means of arrival.

time and means of arrival. All choices are required items in BOTH acute and ER records except "time and means of arrival," which is a required item only for ER documentation.

In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the commission's national patient safety goals, the focus has shifted to the use of abbreviations in the final diagnosis. prohibited use of any abbreviations. use of prohibited or "dangerous" abbreviations. flagrant use of specialty-specific abbreviations.

use of prohibited or "dangerous" abbreviations. As part of its National Patient Safety Goals initiative, the Joint Commission required hospitals to prohibit abbreviations that have caused confusion or problems in their handwritten form, such as "U" for unit, which can be mistaken for "O". Spelling out the word "unit" is preferred.

The final HITECH Omnibus Rule expanded some of HIPAA's original requirements, including changes in immunization disclosures. As a result, where states require immunization records of a minor prior to admitting a student to a school, a covered entity is permitted to dsclose proof of immunication to a school without written authorization of the parent written authorization by the child documentation of any kind any communication with the parent

written authorization of the parent The "Disclosure of Student Immunizations to Schools" provision of the final rule permits a covered entity to disclose proof of immunization to a school (where state law requires it prior to admitting a student) without written authorization of the parent. An agreement must still be obtained and documented, but no signature by the parent is required.