Chapter 6 Review Data Management

Transparency

Create a clear and open documentation process for the information governance strategy and activities within an organization. instruments and clinical information systems.

Compliance

Create a process for ensuring that all the information meetings requirements of appropriate laws, regulations, standards, and organizational policies.

Retention

Create a process for proper preservation of information based on requirements from regulations, accrediting organizations, and company policy.

Accountability

Create authority over the information governance process within an organization.

Disposition

Create processes for secure and appropriate destruction of information that is no longer needed to be maintained by the organization

Institute of Electrical and Electronics Engineers

Creates and develops different standards for hospital systems that need communication between bedside instruments and clinical information systems

Digital Imaging and Communication in Medicine

Creates standards for the messaging of digital images

National Council for Prescription Drug Programs

Creates standards regarding exchanging prescription information and payment information

Health Level 7

Creates standards to support the exchange of clinical information

1. Data field, definition, data type, and format are all common data elements in what? a. Data dictionary b. Data map c. Database d. Data set

a. Data dictionary Rationale: Data field, definition, data type and format are all common data elements in the data dictionary.

8. A patient's birth date and gender documented in the health record are examples of a data? a. Element b. Map c. Dictionary d. Definition

a. Element Rationale: A data element can be a single or individual fact that represents the smallest unique subset of a larger database sometimes referred to as the raw facts and figures.

3. A health information manager took the three elements, blood pressure, weight, and cholesterol to analyze for potential indicators of a heart attack. The combined data is referred to as? a. Information b. Components c. Characterization d. Data

a. Information Rationale: Information is different than data as it refers to data elements that have been combined and then manipulated into something meaningful regarding a patient or a group of patients. For example, a healthcare organization can create a report on the data element's most recent A1C test result and diagnosis of a heart attack analyze and determine if there is a relationship between the A1C test score and a heart attack. By taking the specific data elements of the heart attack diagnoses and the most current A1C result, the healthcare organization can create best practices to enhance patient care based on the findings.

5. AHIMA has created 8 principles to help organizations create ________________ within their organization? a. Information governance b. Data governance c. Data management d. Information management

a. Information governance Rationale: Information governance focuses on principles and oversight to manage the information that is produced from the different systems within an organization. AHIMA defined eight principles to effectively implement information governance: accountability, transparency, integrity, protection, compliance, availability, retention, and disposition.

16. True or false. An example of a clinical documentation improvement tool is computer-assisted coding (CAC). a. True b. False

a. True Rationale: Computer-assisted coding (CAC) is software that has the ability to search and evaluate clinical documentation to produce information regarding potential areas for documentation improvement. Electronic documentation is passed through the CAC software application allowing the information to be analyzed.

20. True or false. A healthcare organization must ensure that data is presented in a way that is appropriate for the purpose of the data. a. True b. False

a. True Rationale: Data visualization and presentation is an important aspect of data management within a healthcare organization. With the vast amount of data available with different system, it is important that the data is presented in ways that are appropriate to the organization and the data being analyzed. It also must represent meaningful and detailed data intended for the specific purpose in which it is needed.

Disambiguated data

the act or process of distinguishing between similar things, meanings, names, etc., in order to make the meaning or interpretation more clear or certain.

23. True or false. An example of a standard for forms development is to mandate that the title of the form appear on the top center of the page. a. True b. False

a. True Rationale: Form standards are written guidelines that create minimal standards for forms requirements within an organization. Form standards are essential to ensure that appropriate design and production practices are followed.

21. True or false. Hospital bylaws define the process for documentation within a health record for all members of the workforce. a. True b. False

a. True Rationale: Hospital bylaws are written documents that govern the staff members (outside of medical staff) who create data within the record for additional support of patient care and reimbursement.

18. True or false. Interoperability is the capability of two or more systems and software applications to communicate electronically and exchange information. a. True b. False

a. True Rationale: Interoperability is the capability of two or more information systems and software applications to communicate and exchange information.

9. Which of the following data sets collect information on the provider, place of encounter, reason for encounter, problem, diagnosis, assessment, therapeutic services, preventative services, and disposition? a. Uniform Ambulatory Care Data Set (UACDS) b. Outcomes and Assessment Information Set (OASIS) c. Data Elements for Emergency Department Systems (DEEDS) d. Uniform Hospital Discharge Data Set (UHDDS)

a. Uniform Ambulatory Care Data Set (UACDS) Rationale: A standardized data set for the ambulatory setting was created known as the Uniform Ambulatory Care Data Set (UACDS). With less data elements than the UHDDS, the UACDS collects data specific to ambulatory care settings with the intent to improve data comparison across the different settings of healthcare. The main data collected in the UACDS is data sets collect information on the provider, place of encounter, reason for encounter, problem, diagnosis, assessment, therapeutic services, preventative services and disposition.

15. This type of data entered into electronic systems is free text and has no specific requirements or rules for data entry. a. Unstructured data b. Structured data c. Formatted data d. Unformatted data

a. Unstructured data Rationale: Unstructured data refers to the data entered into the electronic system that is freely entered into the system. Unstructured data has not rules, requirements, or configurations when entered into the electronic system.

12. The Health Information Director is given responsibility to manage the information and access to the deficiency module, clinical coding module, and release of information module with the electronic health record. This is an example of what data strategy method? a. Data standardization and integration b. Data ownership c. Data management d. Data stewardship

b. Data ownership Rationale: Data ownership is the process of making leaders within the organization responsible for specific areas of the system where data is being entered. Based on the business need, the business owners are responsible to create business rules and definitions when collecting specific data to support patient care and their business operations.

22. True or false. When documentation is unclear or needs more information in order to proper code the health record, the coder should call the provider, ask them the question, and document the answer in the health record. a. True b. False

b. False Rationale: A coder would be acting out of scope of the role of the job to call the provider, get clarification or additional information, and then document the information for coding purposes. Instead, the coder should use the query process, which creates the discussion with the healthcare provider through a template (paper or electronic). The provider is the individual that provides additional information and documents it appropriately, per the medical staff bylaws.

19. True or false. Data warehousing is the process of extracting information stored in structured data formats within a database. a. True b. False

b. False Rationale: Data mining is the processing of extracting from a database or data warehouse information stored in discrete, structured data format. Data warehousing is the process of collecting the data from different data sources within an organization and storing it in a single database that can be used for decision making.

17. True or false. When writing a query for clinical documentation questions, the requestor should specifically state what diagnosis they are evaluating. a. True b. False

b. False Rationale: When writing queries, regardless of medium, healthcare organizations must make sure they are not leading the physicians to document a particular response, but rather to request clarification or provide additional specification.

14. Safeguards established to support the data is available when and where is it needed under the data quality model is called which of the following? a. Approachability b. Timeliness c. Accessibility d. Relevancy

c. Accessibility Rationale: Accessibility of data is making sure it is available to support patient care and business operations at any point in time. Proper safeguards must be established and employed to ensure the data is available when needed while implementing proper precautions and safeguards to protect the information.

7. What is another term for the electronic sharing of patient data between two healthcare systems? a. Interoperability b. Data interchange standards c. Health information exchange d. Electronic data interchange

c. Health information exchange Rationale: Data sharing is the electronic exchange of information between providers' electronic systems and is also known as health information exchange.

11. What is the term that describes the data that defines and characterizes other data within an electronic system? a. Data quality b. Data element c. Metadata d. Source data

c. Metadata Rationale: Metadata refers to the data that characterizes other data such as creation date of data, data sent, date received, last accessed date, and last modification date.

2. A single or individual fact that represents a patient in healthcare is known as a/n ____________. a. Information element b. Database element c. Data dictionary d. Data element

d. Data element Rationale: A data element can be a single or individual fact that represents the smallest unique subset of a larger database sometimes referred to as the raw facts and figures. Examples of data elements include age, gender, blood pressure, temperature, test results, and date of birth.

6. Authorship validation is one part of ___________________________? a. Data management b. Data quality c. Data mapping d. Data integrity

d. Data integrity Rationale: Data integrity is the assurance that the data entered into an electronic system or maintained on paper are only accessed and amended by individuals with the authority to do so. Data integrity includes data governance, patient identification, authorship validation, amendments and record correction, and audit validation for reimbursement purposes.

10. Which of the following creates a visual process to understand the data being collected in two different systems and how it is linked to one another? a. Data evaluation b. Data warehousing c. Data mining d. Data mapping

d. Data mapping Rationale: Data mapping is a process that allows for connections between two systems. A data map creates a process to evaluate the disparity between two systems and links the data being collected together. The intent of conducting data mapping is to ensure the data exchange from one database to another is done in a meaningful way and maintains the integrity of the data.

13. ___________________________ are the information collected within a healthcare organization during the normal day to day operations that supports patient care and business operations? a. Data assets b. Information elements c. Data elements d. Information assets

d. Information assets Rationale: Healthcare organizations collect a lot of data to support the care of the patient as well as business operations such as billing and coding. The information that is collected and used to support the organization is referred to as information assets.

4. The data characteristic that refers to promptly entering up-to-date information into the patient's medical record is which of the following? a. Consistency b. Comprehensiveness c. Relevancy d. Timeliness

d. Timeliness Rationale: Timeliness of patient information refers to entering information promptly to ensure up-to-date information is available within specified and required time frames.