Him141 Chapter 6

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?

Accessibility

The ______________ characteristic of quality data is the data being completely free from any errors?

Accuracy

The process that focuses on the improving the quality and integrity of patient data while supporting timely coding and reimbursement is known as ________.

Clinical documentation improvement

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

Comprehensiveness

Data field, definition, data type, and format are all common data elements in what?

Data dictionary

A single or individual fact that represents a patient in healthcare is known as a/n ____________

Data element

This concept includes the process of data governance, patient identification, authorization validation, amendments and record corrections, and audit validation.

Data integrity

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?

Data mapping

The evaluation of data collected based on business needs and strategy is part of _______.

Data stewardship

Which of the following is a collection of data that is organized in a manner to be accessed, managed, reported, and updated electronically?

Database

Which of the following is the process of execution, implementation, and management of databases within healthcare?

Database life cycle

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

Disease index

Name three other common electronic data sources in healthcare are:

EHR MPI Radiology Information System

A patient's birth date and gender documented in the health record are examples of a data?

Element

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

Facility's data dictionary

True or false. Information is single elements that define a specific characteristic about a patient.

False

True or false. The process of creating paper forms to serve a business need is referred to as form creation. True False

False

What are the names of the standard development organizations that focus on creating standards in the following areas: Exchange of clinical information Messaging of digital images

HL7 (Health Level 7) DICOM (Digital Imaging and Communication in Medicine)

What is another term for the electronic sharing of patient data between two healthcare systems?

Health information exchange

A/n ___________________ is a list that provides guidance, indication, or other references of information contained in a database?

Index

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?

Information

___________________________ are the information collected within a healthcare organization during the normal day to day operations that supports patient care and business operations?

Information assets

What concept refers to the process of creating management and oversight of data assets to support the organization's mission, vision, and values?

Information governance

Which of the following describes the capability for two or more electronic systems to communicate and exchange information electronically?

Interoperability

Which index is used by the HIM department to link the patient's name and number in relations to access and retention of the clinical record?

Master patient index

This document defines how records and documentation are assembled and authenticated within the hospital

Medical staff bylaws

What is the term that describes the data that defines and characterizes other data within an electronic system?

Metadata

What data quality characteristic is met when documenting the specific height of a patient within the health record?

Precision

A/n ________________________ is a communication tool that during clinical documentation improvement is used to communicate between a clinical documentation improvement professional and the provider?

Query

Which of the following is an example of an electronic data source in healthcare?

Radiology Information System

The process of completing an inventory of all electronic systems that create, transmit, and store health information is known as what?

System characterization

The data characteristic that refers to promptly entering up-to-date information into the patient's medical record is which of the following?

Timeliness

The term that refers to an individual's ability to analyze, assess, and reconstruct a situation to provide a solution is critical thinking.

True

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?

Uniform Ambulatory Care Data Set (UACDS)

Which of the following datasets was created to collect uniform data across the United States for inpatient patient stays?

Uniform Hospital Discharge Data Set (UHDDS)/ chequear

This type of data entered into electronic systems is free text and has no specific requirements or rules for data entry

Unstructured data

The term that refers to an individual's ability to analyze, assess, and reconstruct a situation to provide a solution is

critical thinking

True or false. Organization information management is the processes and functions created by an organization to help plan, organize, and coordinate people, processes, technology, and content to manage information systems. True False

false

What does a healthcare organization create when it has a unique numbering system to identify all forms used within the organization? Forms standardization system Forms distribution system Forms quality management system Form tracking system

form trach=king system

Which of the following is one of the principles of data stewardship as defined by the National Committee on Vital and Health Statistics (NCVHS)? Individual's rights Accuracy of patient information Individual's responsibilities Completeness of patient information

individuall's rights/ chequear

True or false. Structured data is data that is entered into a specific format that is capable of being read and analyzed without human intervention. True False

true

True or false. The master patient index is maintained by the healthcare organization and contains patient demographic information such as name, date of birth, and health record number. True False

true

True or false. The oversight of the definition of structure of data elements as well as the creation, storage, and transmission of data elements is referred to as data management. True False

true