RHIT Exam Prep 2017 Domain 1: Data Content, Structure, and Information Governance, RHIT Exam Prep 2018 Domain 2: Access, Disclosure, Privacy, and Security, RHIT Exam Prep 2018 Domain 3: Data Analytics and Use, Domain 4: Revenue Cycle Management, Doma...

A patient's gender, phone number, address, next of kin, and insurance policy holder information would be considered what kind of data?

Administrative data Administrative describes patient identification, diagnosis, procedures, and insurance. Patient registration information would be considered administrative data as would patient account information. A significant portion of administrative data is demographic data

Which of the following is an example of clinical data?

Admitting diagnosis The health record generally contains two types of data: clinical and administrative. Clinical data document the patient's health condition, diagnosis, and procedures performed as well as the healthcare treatment provided. Administrative data include demographic and financial information as well as various consents and authorizations related to the provision of care and the handling of confidential patient information

Which of the following represents an example of data granularity?

A numerical measurement carried out to the appropriate decimal place Data granularity requires that the attributes and values of data be defined at the correct level of detail for the intended use of the data. For example, numerical values for laboratory results should be recorded to the appropriate decimal place as required for the meaningful interpretation of test results—or in the collection of demographic data, data elements should be defined appropriately to determine the differences in outcomes of care among various populations

The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards is called:

Accreditation Accreditation is the act of granting approval to a healthcare organization. The approval is based on whether the organization has met a set of voluntary standards that were developed by the accreditation agency. Voluntary reviews are conducted at the request of the healthcare facility seeking accreditation or certification. The Joint Commission is an example of an accreditation agency.

You are the director of HIM at Community Hospital. A physician has asked for the total number of appendectomies that he performed at your hospital last year. What type of data will you provide the physician with?

Aggregate data Aggregate data is data extracted from individual health records and combined to form deidentified information about groups of patients that can be compared and analyzed.

Cancer registries receive approval as part of the facility cancer program from which of the following agencies?

American College of Surgeons Several organizations have developed standards or approval processes for cancer programs. The American College of Surgeons (ACS) Commission on Cancer has an approval process for cancer programs. One of the requirements of this process is the existence of a cancer registry as part of the program.

A healthcare provider organization, when defining its legal health record must:

Assess the legal environment, system limitations, and HIE agreements As part of the process to identify the legal health record, the facility should assess the legal environment, system limitations, and HIE agreements

A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled." In which part of a problem-oriented health record progress note would this be written?

Assessment Some providers also use a SOAP format for their problem-oriented progress notes. Professional conclusions reached from evaluation of the subjective or objective information make up the assessment (A)

Which of the following is not a recommended guideline for maintaining integrity in the health record?

Assuring documentation that is being changed is permanently deleted from the record 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. These functions ensure that the data is protected and altered by authorized individuals as per policy.

Which of the following is the best definition of system of record (SOR)?

Authoritative source for data about an entity Once the organization identifies sources, it lists the most trusted ones. Usually these are the sources with the most volume of master data records associated with a specific entity. In some instances, the master data will have their own unique system of record. A system of record is usually a specialized application system and the authoritative source for data about an entity.

Hospital physical documents relating to the delivery of patient care such as health records, x-rays, laboratory reports, and consultation reports are owned:

By the hospital Health records, x-rays, laboratory reports, consultation reports, and other physical documents relating to the delivery of patient care are owned by the healthcare organization

Which of the following is considered a secondary data source?

Cancer registry Secondary data sources are data collected or extracted from a primary data source and used for purposes other than their original intended use. Secondary data sources are frequently maintained in registries, databases or indexes, such a cancer registry.

What committee usually oversees the development and approval of new forms for the health record?

Clinical forms committee Every healthcare organization should have a forms or design (for EHR systems) committee. This committee should provide oversight for the development, review, and control of all enterprise-wide information capture tools, including paper forms and design of computer screens

The HIM department is planning to scan paper-based components of the medical record such as consent forms and lab orders from physician offices. Which of the following methods would be best to help HIM professionals monitor the completeness of health records during a patient's hospitalization?

Concurrent scanning Digital scanners create images of handwritten and printed documents that are then stored in health record databases as electronic files. The data can be interfaced in the current EHR with the document scanning system. Performing the scanning function concurrently improves the ability for the HIM staff to ensure completeness of the health record

Which of the following documentation must be included in a patient's health record prior to performing a surgical procedure?

Consent for operative procedure, history, physical examination Documentation of health history, consents, and the physical examination must be available in the patient's record before any surgical procedures may be performed

Two coders have found the same abbreviation on two records. One abbreviation of "O.D." was used on an eye health record to mean "right eye." The other abbreviation on another patient's record was used to mean "overdose" on an abuse record. What data quality component is lacking here?

Consistency Characteristics for data entry should be uniform throughout the health record to ensure consistency. Abbreviations are extremely easy to use; however, data must have definitions and be uniform to prevent information inconsistencies.

A family practitioner requests the opinion of a physician specialist who reviews the patient's health record and examines the patient. The physician specialist would record findings, impressions, and recommendations in what type of report?

Consultation The consultation report documents the clinical opinion of a physician other than the primary or attending physician. The report is based on the consulting physician's examination of the patient and a review of his or her health record.

Which of the following is a risk of copy and pasting?

Copying the note in the wrong patient's record In the EHR, the user is able to copy and paste free text from one patient or patient encounter to another. This practice is dangerous as inaccurate information can easily be copied. One of the risks to documentation integrity of using copy functionality includes propagation of false information in the record

What is the status conferred by a national professional organization that is dedicated to a specific area of healthcare practice?

Credential Credentials are the recognition by healthcare organizations of previous professional practice responsibilities and experiences commonly accorded to licensed independent practitioners and are usually conferred by a national professional organization dedicated to a specific area of healthcare practice

Which of the following data sets would be most helpful in developing a hospital trauma data registry?

DEEDS In 1997, the Centers for Disease Control and Prevention (CDC), through its National Center for Injury Prevention and Control (NCIPC), published a data set called Data Elements for Emergency Department Systems (DEEDS). The purpose of this data set is to support the uniform collection of data in hospital-based emergency departments and to reduce incompatibilities in emergency department records.

Which of the following is not a characteristic of high-quality healthcare data?

Data accountability The data quality model applies the following quality characteristics: data accuracy, data accessibility, data comprehensiveness, data consistency, data currency, data definition, data granularity, data precision, data relevancy, and data timeliness

At admission, Mrs. Smith's date of birth is recorded as 3/25/1948. An audit of the EHR discovers that the numbers in the date of birth are transposed in reports. This situation reflects a problem in:

Data consistency Consistency means ensuring the patient data is reliable and the same across the entire patient encounter. In other words, patient data within the record should be the same and should not contradict other data also in the patient record

Mrs. Smith's admitting data indicates that her birth date is March 21, 1948. On the discharge summary, Mrs. Smith's birth date is recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record?

Data consistency Data consistency means that the data are reliable. Reliable data do not change no matter how many times or in how many ways they are stored, processed, or displayed. Data values are consistent when the value of any given data element is the same across applications and systems. Related data items also should be reliable.

Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missing from the progress note?

Data currency Data currency and data timeliness mean that healthcare data should be up-to-date and recorded at or near the time of the event or observation. Because care and treatment rely on accurate and current data, an essential characteristic of data quality is the timeliness of the documentation or data entry.

In a database the LAST_NAME column in a table would be considered a:

Data element A data element is an individual fact or measurement that is the smallest unique subset of a database

Patient name, zip code, and health record number are typical:

Data elements The types of data elements that are abstracted, or defined as indexed fields in an automated system, vary from facility to facility. Generally, however, any data elements that are needed for selecting cases for reports must be abstracted or indexed. Some of the typical data fields that can be searched for the purpose of finding and reporting include: patient name, zip code, health record number, patient account number, attending physician, and the like

Which of the following Enterprise Information Management (EIM) functions is the overarching authority for managing an organization's data assets?

Data governance Data governance is the overarching authority that ensures the cohesive operation and integration of all EIM domains. Data governance includes a formal organizational structure with both authority and responsibility for managing an organization's data assets

Which of the following best describes data comprehensiveness?

Data include all required elements. Data comprehensiveness means that all the required data elements are included in the health record. In essence, comprehensiveness means that the record is complete. In both paper-based and computer-based systems, having a complete health record is critical to the organization's ability to provide excellent patient care and to meet all regulatory, legal, and reimbursement requirements

The patient's address is the same in the master patient index, electronic health record, laboratory information system, and other systems. This means that the data values are consistent and therefore indicative of which of the following?

Data integrity Data integrity means that data are complete, accurate, consistent, and up-to-date so it is reliable.

The HIM manager is conducting a study in which she is comparing the current year's diagnosis codes to the proposed new codes for the next fiscal year and documenting variations in order to assess the impact on the organization. This process creates a:

Data map Data mapping is a process that allows for connections between two systems. For example, mapping two different coding systems to show the equivalent codes allows for data initially captured for one purpose to be translated and used for another purpose.

Which of the following individuals would serve as a bridge between information technology and business and clinical areas while managing each key area?

Data steward Data stewards serve as the bridge between information technology, and business and clinical areas. They are assigned to manage key data areas and are responsible for tasks such as data definition and information quality activities.

Which of the following would be a discriminating attribute used to disqualify two or more similar records?

Date of birth Discriminating attributes are used to disqualify two or more similar records, rather than match them. These should be static attributes that do not normally change such as date of birth.

A health record with deficiencies that is not completed within the timeframe specified in the medical staff rules and regulations is called a(n):

Delinquent record When an incomplete record is not rectified within a specific number of days as indicated in the medical staff rules and regulations, the record is considered to be a delinquent record. The HIM department monitors the delinquent record rate very closely to ensure compliance with accrediting standards.

Which of the following is the best definition of a data governance framework?

Describes a real or conceptual structure that organizes a system or concept A data governance framework is a real or conceptual structure that organizes a system or concept. A framework typically describes and shows the synergy and interrelation among different part of an approach.

What is the first step an organization should take when developing a data dictionary?

Design a plan The data dictionary should be designed to accommodate changes resulting from clinical or technical advances and regulatory changes. There should be a plan for future expansion, such as expanding a data field from one element to multiple elements. This becomes problematic when comparing data across time if the meaning of a particular element has changed while its name or representation has not

The hospital currently has a hybrid health record. Nurses and clinicians are recording bedside documentation electronically in a clinical documentation system, while most other documentation, such as physician progress notes and orders, are paper based and stored in a paper health record, making retrieval of the complete record after discharge difficult and risking the record's integrity. Given these circumstances, which of the following should the HIM director implement to alleviate these problems and preserve the efficiencies of an electronic record?

Digitally scan all paper records postdischarge, and integrate and index these into the existing electronic document management system Many hospitals incorporate documents into their EHR systems. Digital scanners create images of handwritten and printed documents that are then stored in health record databases as electronic files in their electronic document management system (EDMS). Using scanned images solves many of the problems associated with traditional paper-based health records and hybrid records

Which of the following is a primary purpose of the health record?

Document patient care delivery Patient care delivery is a primary purpose of the health record. Other primary purposes are patient care management, patient care support processes, financial and other administrative processes, and patient self-management

In designing an input screen for an EHR, which of the following would be best to capture structured data?

Drop-down menus Structured data are data that are able to be read and interpreted by a computer. Examples of structured data include check boxes, drop-down boxes, and radio buttons

The following is documented in an acute-care record: "Atrial fibrillation with rapid ventricular response, left axis deviation, left bundle branch block." In which of the following would this documentation appear?

ECG report Documentation of these results would typically be found in the ECG report

A coding analyst consistently enters the wrong code for patient gender in the computer billing system. What measures should be in place to minimize this data entry error?

Edit checks Edit checks assist in ensuring data integrity by allowing only reasonable and predetermined values to be entered into the computer

Authentication of a record refers to:

Establishment of its baseline trustworthiness Even if evidence appears to be relevant, it must also be authenticated. As with health records, the evidence itself must be shown to have a baseline authenticity or trustworthiness

Patient care managers use the data documented in the health record to:

Evaluate patterns and trends of patient care Patient care managers are responsible for the overall evaluation of services rendered for their particular area of responsibility. To identify patterns and trends, they take details from individual health records and put all the information together in one place

This data set was developed by the National Committee for Quality Assurance to aid consumers with health-related issues with information to compare performance of clinical measures for health plans:

HEDIS Healthcare Effectiveness Data and Information Set (HEDIS) is overseen by the National Committee for Quality Assurance. HEDIS is a standardized set of performance measures designed to allow purchasers to compare the performance of managed-care plans/

A new HIM director has been asked by the hospital CIO to ensure data content standards are identified, understood, implemented, and managed for the hospital's planned EHR system. Which of the following should be the HIM director's first step in carrying out this responsibility?

Identify data content requirements for all areas of the organization Data content standards allow organizations to collect data once and use it many times in many ways. They also assist in data storage and mining as well as sharing data with external organizations for use in benchmarking and other purposes. The HIM director should identify data content requirements for all areas of the organization to ensure the data content standards are met.

Which of the following is the goal of the quantitative analysis performed by HIM professionals?

Identifying deficiencies early so they can be corrected Reviewing for deficiencies is an example of quantitative analysis. The goal of quantitative analysis is to make sure there are no missing reports, forms, or required signatures in a patient record. Timely completion of this process ensures a complete health record.

In which of the following examples does the gender of the patient constitute information rather than a data element?

In a study comparing the incidence of myocardial infarctions in black males as compared to white females Data are the raw elements that make up our communications. Humans have the innate ability to combine data they collect and, through all their senses, produce information (which is data that have been combined to produce value) and enhance that information with experience and trial-and-error that produces knowledge. In this example, the gender is tied to race in the data collection that constitutes information and not a data element

On the problem list in a problem-oriented health record, problems are organized:

In numeric order The problem-oriented health record is better suited to serve the patient and the end user of the patient information. The key characteristic of this format is an itemized list of the patient's past and present social, psychological, and health problems. Each problem is indexed with a unique number

Which of the following is an argument against the use of the copy and paste function in the EHR?

Inability to identify the author In the EHR, the user is able to copy and paste free text from one patient or patient encounter to another. This practice is dangerous as inaccurate information can easily be copied. One of the risks to documentation integrity of using copy functionality includes the inability to identify the author of the documentation

The hospital is revising its policy on health record documentation. Currently, all entries in the health record must be legible, complete, dated, and signed. The committee chairperson wants to add that all entries must have the time noted. However, another clinician suggests that adding the time of notation is difficult and rarely may be correct because personal watches and the hospital clocks may not be coordinated. Another committee member agrees and says that only electronic documentation needs a time stamp. Given this discussion, which of the following might the HIM director suggest?

Inform the committee that according to the Conditions of Participation, all documentation must include date and time All patient health record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures

Which of the following are data that have been filtered and put into context?

Information Information moves beyond data and consists of sets of data that are related and have been placed in context, are filtered, manipulated, or formatted in some way and are useful to a particular task

Information assets are:

Information considered to add value to an organization Information assets refer to the information collected during day-to-day operations of a healthcare organization that has value within an organization. For example, patient data collected to support patient care is an example of information assets for the organization

The term used to describe controlling information is ________.

Information governance Information governance is the accountability framework and decision rights to achieve enterprise information management.

When a user keys in 10101963, the computer displays it as 10/10/1963. What enables this?

Input mask Data is collected in a number of ways. The information system should have measures in place to control the data entered into the EHR. In this example, the birth date of 10101963 is displayed in the computer as 10/10/1963 because an input mask was used in the information system to show the format in which the data will be displayed .

What is the term that is used to mean ensuring that data are not altered during transmission across a network or during storage?

Integrity The goals of the HIPAA security rule are to ensure the confidentiality, integrity, and availability of electronically created protected health information (PHI). Integrity is ensuring that data are not altered either during transmission across a network or during storage. e-PHI must be available when needed for patient care and other uses.

The ability to electronically send data from one EHR to another while maintaining the original meaning is called:

Interoperability Interoperability refers to the use of standard protocols to enable two different computer systems to share data with each other

Which of the following elements is not a component of most patient health records?

Invoice for services Besides storage of patient care documentation, the health record has other equally important functions. These include helping physicians, nurses, and other caregivers make diagnoses and choose treatment options. Invoices for services would not be part of the patient health record.

Results of a urinalysis and all blood tests performed would be found in what part of a healthcare record?

Laboratory findings The results of all diagnostic and therapeutic procedures become part of the patient's health record. Diagnostic procedures include laboratory tests performed on blood, urine, and other samples from the patient which would be documented in the laboratory findings

Before healthcare organizations can provide services, they usually must obtain ________ by government entities such as the state or county in which they are located.

Licensure Compliance with state licensing laws is required in order for healthcare organizations to begin or remain in operation within their states. To continue licensure, organizations must demonstrate their knowledge of, and compliance with, documentation regulations

An RAI/MDS and care plan are found in records of patients in what setting?

Long-term care The long-term care health record contains the patient's registration forms, personal property list, RAI/MDS, care plan and discharge or transfer information.

The link that tracks patient, person, or member activity within healthcare organizations and across patient care settings is known as:

Master patient index (MPI) The MPI is a list or database created or maintained by a healthcare facility to record the name and identification number of every patient and activity that has ever been admitted or treated in the facility.

Which of the following describe criteria with specific objectives and measures that hospitals must meet to demonstrate they are using EHRs that positively affect patient care?

Meaningful use Meaningful use is criteria with specific objectives and measures to be met by hospitals to demonstrate they are using EHRs that positively affect patient care

Which of the following is the health record component that addresses the patient's current complaints and symptoms and lists that patient's past medical, personal, and family history?

Medical history A complete medical history documents the patient's current complaints and symptoms and lists his or her past health, personal, and family history. In acute care, the health history is usually the responsibility of the attending physician

Which of the following represents documentation of the patient's current and past health status?

Medical history A complete medical history documents the patient's current complaints and symptoms and lists his or her past health, personal, and family history. In acute care, the health history is usually the responsibility of the attending physician

Which of the following is the health record component that addresses the patient's current complaints and symptoms and lists that patient's past medical, personal, and family history?

Medical history A complete medical history documents the patient's current complaints and symptoms and lists his or her past health, personal, and family history. In acute care, the health history is usually the responsibility of the attending physician.

A health data analyst has been asked to compile a report of 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?

Medication administration record and clinical laboratory reports 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.

Activities of daily living (ADL) are components of:

OASIS-C Outcomes and Assessment Information Set (OASIS-C) is a standardized data set of more than 30 data elements designed to gather data about Medicare beneficiaries who are receiving services from a home health agency.

Which of the following is not part of data governance?

Promoting the sale of enterprise data Data governance is the enterprise authority that ensures control and accountability for enterprise data through the establishment of decision rights and data policies and standards that are implemented and monitored through a formal structure of assigning roles, responsibilities, and accountabilities. Promoting the sale of data would not be a role of data governance

Identify where the following information would be found in the acute-care record: "Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion."

Operative report The operative report describes the surgical procedures performed on the patient. The operative report should be written or dictated by the surgeon immediately after surgery and become part of the health record.

OASIS-C data are used to assess the ________ of home health services.

Outcome The Outcomes and Assessment Information Set (OASIS-C) consists of data elements that represent core items for the comprehensive assessment of an adult home care patient and form the basis for measuring patient outcomes for the purpose of outcome-based quality improvement

Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers?

Outcomes and Assessment Information Set Medicare-certified home healthcare uses a standardized patient assessment instrument called the Outcomes and Assessment Information Set (OASIS-C). OASIS-C items are components of the comprehensive assessment that is the foundation for the plan of care

In which department or unit is the health record number typically assigned?

Patient registration The health record number is a key data element in the MPI. It is used as a unique personal identifier and is also used in paper-based numerical filing systems to locate records and in electronic systems to link records. Although it is typically assigned at the point of patient registration, the HIM department is usually responsible for the integrity of health record number assignment and for ensuring that no two patients receive the same number

Physician orders for DNR and DNI should be consistent with:

Patient's advance directive An advanced directive is a written document that provides directions about a patient's desires in relation to care decisions for use by health care workers if the patient is incapacitated or not capable of communication. Physician orders for "do not resuscitate" (DNR) and "do not attempt intubation" (DNI) should be consistent with the patient's advanced directives

Which of the following would be the best technique to ensure that registration clerks consistently use the correct notation for assigning admission date in an EHR?

Provide a template for entering data in the field Templates are a cross between free text and structured data entry. The user is able to pick and choose data that are entered frequently, thus requiring the entry of data that change from patient to patient. Templates can be customized to meet the needs of the organization as data needs change by physician specialty, patient type (surgical/medical/newborn), disease, and other classification of patients. In this situation a template would provide structured data entry for the admission date.

Version control of documents in the EHR requires:

Policies and procedures to control which version(s) is displayed The health record may have multiple versions of the same document; for example, a signed and an unsigned copy of a document. To address the issues that result from having multiple versions of the same document, policies and procedures addressing version control must be developed.

The coding manager at Community Hospital is seeing an increased number of physicians failing to document the cause and effect of diabetes and its manifestations. Which of the following will provide the most comprehensive solution to handle this documentation issue?

Present this information at the next medical staff meeting to inform physicians on documentation standards and guidelines. The quality of the documentation entered in the health record by providers can have major impacts on the ability of coding staff to perform their clinical analyses and assign accurate codes. In this situation, the best solution would be to educate the entire medical staff on their roles in the clinical documentation improvement process. Explaining to them the documentation guidelines and what documentation is needed in the record to support the more accurate coding of diabetes and its manifestations will reduce the need for coders to continue to query for this clarification

At the time a hospital implemented an electronic health record, the Health Record Committee determined that all records of patients who have not been treated at the facility in the past two years would be moved to an inactive file area. These patient records are considered ________ from the active filing area.

Purged Files of patients who have not been at the facility for a specified period, such as two years, may be purged or removed from the active filing area. The time period and frequency of purging depends on the space available, patient readmission rate, and the need for access to the health record

George reviewed the patient record of Mr. Brown and found there was no H&P on the record at seven hours past this patient's admission time. This review process would be an example of:

Quantitative analysis Quantitative analysis is used by health information management technicians as a method to detect whether elements of the patient's health record are missing

What is the primary purpose of structured data entry?

Reduce documentation variability Structured data entry techniques constrain data capture into a common format or vocabulary. A purpose of structured data entry is to reduce variability in terminology, allowing for standardization.

HIM departments may be the hub of identifying, mitigating, and correcting MPI errors, but that information often is not shared with other departments within the healthcare organization. After identifying procedural problems that contribute to the creation of the MPI errors, which department should the MPI manager work with to correct these procedural problems?

Registration A review of the identified duplicates and overlays often reveals procedural problems that contribute to the creation of errors. Although health information management (HIM) departments may be the hub of identifying, mitigating, and correcting master patient index (MPI) errors, that information may never be shared with the registration department. If the registration staff is not aware of the errors, how can they begin to proactively prevent the errors from occurring in the first place? Registration process improvement activities can eventually reduce work for HIM departments. In addition, monitoring new duplicates is a critical process, and tracking reports should be created and implemented. Identifying and reporting MPI errors is important; however, tracking who made the error and why will decrease the number of duplicates

In a routine health record quantitative analysis review, it was found that a physician dictated a discharge summary on 1/26/20XX. Because of unexpected complications, however, the patient was discharged two days after the discharge summary was dictated. What would be the best course of action in this case?

Request that the physician dictate an addendum to the discharge summary If during record analysis, missing or incomplete information is identified, HIM personnel can issue deficiency notification(s) to the appropriate caregiver to assure the completeness of the health record. An addendum is a supplement to a signed report that provides additional health information within the health record. In this type of correction, a previous entry has been made and the addendum provides additional information to address a specific situation or incident

A secondary purpose of the health record is to provide support for which of the following?

Research The secondary purposes of the health record are not associated with specific encounters between patient and healthcare professional. Rather, they are related to the environment in which patient care is provided. Some secondary purposes are: support for research, to serve as evidence in litigation, to allocate resources, to plan market strategy, and the like.

Which of the following should be avoided when designing forms for an electronic document management system (EDMS)?

Shading of bars or lines that contain text The use of colored paper or ink other than black, or shading of text in EDMS should be minimized or eliminated because the color can adversely affect the quality of scanned images

What type of standards provide clear descriptors of data elements to be included in computer-based patient record systems?

Structure and content Structure and content standards establish and provide clear and uniform definitions of the data elements to be included in EHR systems. They specify the type of data to be collected in each data field and the attributes and values of each data field, all of which are captured in data dictionaries

Which of the following is a secondary purpose of the health record?

Support for research Healthcare is a sophisticated industry and information from the health record is used for many purposes not related specifically to patient care. These secondary purposes include support for public health and research

Which of the following provides a standardized vocabulary for facilitating the development of computer-based patient records?

Systematized Nomenclature of Medicine Clinical Terminology Standardized vocabulary is needed to facilitate the indexing, storage, and retrieval of patient information in an electronic health record (EHR). Systematized Nomenclature of Medicine Clinical Terminology (SNOMED CT) creates a standardized vocabulary. The Computerbased Patient Record Institute (CPRI) has studied the ability of current nomenclatures to capture information for EHRs. The institute has determined that SNOMED CT is the most comprehensive controlled vocabulary for coding the contents of the health record and facilitating the development of computerized records.

Which of the following has been responsible for accrediting healthcare organizations since the mid-1950s and determines whether the organization is continually monitoring and improving the quality of care provided?

The Joint Commission The Joint Commission has been the most visible organization responsible for accrediting healthcare organizations since the mid-1950s. The primary focus of the Joint Commission at this time is to determine whether organizations seeking accreditation are continually monitoring the quality of the care they provide. The Joint Commission requires that this continual improvement process be in place throughout the entire organization, from the governing body down, as well as across all department lines

Which of the following would be considered a derivation business rule?

The average length of stay is the sum of inpatient days for a period divided by the number of discharges for a period Derivation is an attribute that is derived through a mathematical calculation of inference from other attributes or systems variables.

How many times each year are healthcare facilities required to practice emergency preparedness plans?

Twice The emergency operations plan is practiced twice a year in response either to an actual disaster or to a planned drill. Exercises should stress the limits of the organization's emergency management system to assess preparedness capabilities and performance when systems are stressed.

Why should the copy and paste function not be used in the electronic health record?

The content may contain outdated information In the EHR, the user is able to copy and paste free text from one patient or patient encounter to another. This practice is dangerous as inaccurate information can easily be copied and information can be outdated

When creating requirements of documentation for the hospital bylaws, which of the following should be evaluated?

The documentation needs based on accrediting bodies Outside of the medical staff bylaws, hospital bylaws are written documents that govern the staff members who create data within the record for additional support of patient care and reimbursement. Since providers are not the sole authors in the creation of clinical documentation, it is important for hospitals to define who can document within the record, the type of documentation that can occur, and the timeliness and completeness of that documentation. The documentation must also be based on accrediting bodies' expectations.

An outpatient clinic is reviewing the functionality of an EHR it is considering for purchase. Which of the following data sets should the clinic consult to ensure that all the federally recommended data elements for Medicare and Medicaid outpatients are collected by the system?

UACDS The Uniform Ambulatory Care Data Set (UACDS) data characteristics include patient-specific items for outpatient care.

The following descriptors about the data element ADMISSION_DATE are included in a data dictionary: definition: date patient admitted to 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:

The template was defined 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

Which of the following is not a characteristic of the common healthcare data sets such as UHDDS and UACDS?

They provide a complete and exhaustive list of data elements that must be collected. A data set is a list of recommended data elements with uniform definitions that are relevant for a particular use. The contents of data sets vary by their purpose. However, data sets are not meant to limit the number of data elements that can be collected. Most healthcare organizations collect additional data elements that have meaning for their specific administrative and clinical operations. Standardizing data elements and definitions makes it possible to compare the data collected at different facilities. A number of data reporting requirements come from federal initiatives.

A healthcare system wants to map ICD-10-CM to ICD-9-CM. Which of the following would be true about this effort?

This is an example of reverse mapping A reverse map links two systems in the opposite direction, from the newer version of a code set to an older version

How do accreditation organizations use the health record?

To determine whether standards are being met In order to be granted and maintain accreditation, a healthcare organization must show compliance with the accrediting body standards. This frequently requires review of the health record to determine compliance with documentation and patient care standards.

How do accreditation organizations such as the Joint Commission use the health record?

To determine whether standards of care are being met Every participating healthcare organization is subject to a periodic accreditation survey. Surveyors visit each facility and compare its programs, policies, and procedures to a prepublished set of performance standards. A key component of every accreditation survey is a review of the facility's health records. Surveyors review the documentation of patient care services to determine whether the standards for care are being met

Which Joint Commission survey methodology involves an evaluation that follows the hospital experiences of past or current patients?

Tracer methodology The Joint Commission uses tracer methodology for on-site surveys. The tracer methodology incorporates the use of the priority focus process (PFP) review, follows the experience of care through the organization's entire healthcare process, and allows the surveyor to identify performance issues.

A health information technician is responsible for designing a data collection form to collect data on patients in an acute-care hospital. The first resource that she should use is:

UHDDS The purpose of the UHDDS is to list and define a set of common, uniform data elements. The data elements are collected from the health records of every hospital inpatient and later abstracted from the health record and included in national databases

Which of the following is a key characteristic of the problem-oriented health record?

Uses an itemized list of the patient's past and present health problems The problem-oriented health record is better suited to serve the patient and the end user of the patient's information. The key characteristic of this format is an itemized list of the patient's past and present social, psychological, and health problems. Each problem is indexed with a unique number.

Which of the following is not a true statement about a hybrid health record system?

Version control is easy to implement. As the electronic system develops, different versions of documents may exist, and these also must be monitored and logged for both legal and practice purposes. Version control in a hybrid record environment is challenging as both the paper and electronic documents must be controlled