HIT, Chapter 6

What are common data sources in healthcare?

-EHR -Radiology information system -MPI

Types of data sets

-Uniform Hospital Discharge Data Set (UHDDS) -Uniform Ambulatory Care Data Set (UACDS) -Minimum Data Set (MDS) -Outcomes Assessment Information Set (OASIS) -Data Elements for Emergency Department Systems (DEEDS) -Essential Medical Data Set (EMDS)

Information governance principles

-accountability -transparency -integrity -protection -disposition

Use case

Describes how the users will interact with the data map

Query

a CDI communication tool to communicate with providers to obtain clinical clarification or ask a question

Database

a collection of data organized so its contents can be easily accessed, managed, reported, and updated

Index

a list from a database that provides guidance, indication, or other references to the data contained in the database

Data dictionary

a listing of all the data elements that defines each individual data element, standard input, and specific data length

Data sets

a recommended list of data elements that have defined and uniform definitions

Data warehouse

a single database that makes it possible to access data that exists in multiple databases through one query and reporting interface

The ______________ characteristic of quality data is the data being completely free from any errors? a. Accuracy b. Precision c. Comprehensiveness d. Consistency

a. Accuracy

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

a. Individual's rights

A/n ________________________ is a communication tool that during clinical documentation improvement is used to communicate between a clinical documentation improvement professional and the provider? a. Query b. Outcomes and Assessment Information Set (OASIS) c. Data Elements for Emergency Department Systems (DEEDS) d. Uniform Ambulatory Care Data Set (UACDS)

a. Query

Which of the following is an example of an electronic data source in healthcare? a. Radiology Information System b. Patient consent for treatment c. Dictation system d. Patient's driver's license

a. Radiology Information System

True or false. Data modeling is the process of creating documentation to document any business decisions made on data collection and storage systems for data. a. True b. False

a. True

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. a. True b. False

a. 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. a. True b. False

a. 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. a. True b. False

a. True

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

a. True

Database Life Cycle (DBLC)

an important step in the proper execution, implementation, and management of databases

Clinical documentation

any manual or electronic notation made by a physician related to a patient's medical condition/treatment

The evaluation of data collected based on business needs and strategy is part of _______. a. Data ownership b. Data stewardship c. Data quality b. Data modeling

b. 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? a. Dataset b. Database c. Data map d. Data index

b. Database

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

b. False

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. a. True b. False

b. False

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

b. False

What data quality characteristic is met when documenting the specific height of a patient within the health record? a. Comprehensiveness b. Precision c. Definition d. Relevancy

b. Precision

The process that focuses on the improving the quality and integrity of patient data while supporting timely coding and reimbursement is known as ________. a. Data collection and accuracy process b. Data quality management c. Clinical documentation improvement d. Clinical quality enhancement

c. Clinical documentation improvement

This concept includes the process of data governance, patient identification, authorization validation, amendments and record corrections, and audit validation. a. Data reliability b. Data accuracy c. Data integrity d. Data completeness

c. Data integrity

Which of the following is the process of execution, implementation, and management of databases within healthcare? a. Database management b. Database elements c. Database life cycle d. Database operations cycle

c. Database life cycle

What concept refers to the process of creating management and oversight of data assets to support the organization's mission, vision, and values? a. Enterprise information management b. Outcomes and Assessment Information Set (OASIS) c. Information governance d. Data governance

c. Information governance

Data elements

can be a single fact that represents the smallest unique subset of a larger database

Data stewardship

creates responsibility for data through principles and practices to ensure the knowledgeable and appropriate use of data derived from individuals personal health information

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

d. Form tracking system

A/n ___________________ is a list that provides guidance, indication, or other references of information contained in a database? a. Map b. Mining c. Element d. Index

d. Index

Which of the following describes the capability for two or more electronic systems to communicate and exchange information electronically? a. Sharing b. Interchange c. Mapping d. Interoperability

d. Interoperability

This document defines how records and documentation are assembled and authenticated within the hospital. a. Ancillary staff bylaws b. Provider contracts c. Hospital bylaws d. Medical staff bylaws

d. Medical staff bylaws

The process of completing an inventory of all electronic systems that create, transmit, and store health information is known as what? a. System management b. Data mapping c. Data Mapping d. System characterization

d. System characterization

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

d. Uniform Hospital Discharge Data Set (UHDDS)

Provider contracts with facilities

delineate all expectation of the provider as they care for patients in a specific ambulatory care setting

Medical staff bylaws

describe the manner in which providers will practice medicine

Object-oriented database (OODB)

designed to store data including images, audio files, documents, videos, and data elements

Clinical Documentation Improvement (CDI)

facilitate an accurate representation of healthcare services through complete and accurate patient documentation

Data governance

focuses on managing data as it's created within a system

Information governance

focuses on principles and oversight to manage the information that is produced from the different systems within an organization

Data mining

process of extracting from a database or data warehouse information stored in discrete, structured data format

Data mapping

process that allows for connections between two systems

Data management

refers to the definition and structure of data elements and the creation, storage, and transmission of data elements

Data integrity

the assurance that the data entered are only accessed and amended by individuals with the authority to do so

Data warehousing

the process of collecting data from different data sources and storing it in a single database that can be used for decision making

System characterization

the process of creating an inventory of all systems that contain data

Hospital bylaws

written documents that govern the staff members who create data within the record for additional support of patient care and reimbursement

Bylaws

written documents that provide details and information regarding the rules and regulation established by a healthcare organization to help support healthcare operations