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- DOMAIN 1 Data Content, Structure, and Information Governance
- A health record technician has been asked to review the discharge patient abstracting module of a proposed new EHR. Which of the following data sets would the technician consult to en- sure the system collects all federally required discharge data elements for
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UHDDS
The Uniform Hospital Discharge Data Set (UHDDS) data characteristics include pa- tient-specific items on every inpatient. CARF: Commission on Accreditation of Rehabili- tation Facilities Medicare and Medicaid inpatients in an DEEDS: Data Elements for Emergency Depart- acute-care hospital? A. CARF B. DEEDS C. UACDS D. UHDDS
- Standardizing medical terminology to avoid differences in naming vari- ous health conditions and procedures (such as the synonyms bunionectomy, McBride procedures, and repair of the hallux valgus) is one purpose of: A. Content and structure standards B. Security standard c. Transaction standards d. Vocabulary standards
- Patient care managers use the data documented in the health record to:
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ment System UACDS: Uniform Ambulatory Care Data Set Vocabulary Standards Vocabulary Standards are a list or collection of clinical words or phrases with their meanings; also the set of words used by an individual or group within a particular subject field, such as to provide consistent descriptions of medical terms for an individual's condition in the health record. Evaluate patterns and trends of patient care Patient care managers are responsible for the
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a. Vital Signs record b. Initial nursing assessment record c. Physician progress notes d. Admission record The vital signs record is comprised of blood pressure readings, temperature, respiration, and pulse, making it the best source to gather this type of information.
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- Which of the following is a key charac- teristic of the problem-oriented health record? a. Allows all providers to document in the health record b. Uses laboratory reports and other diagnostic tools to determine health problems 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 characteris- tic of this format is an itemized list of the pa- tient's past and present social, psychological, and health problems. Each problem is indexed c. Provides electronic documentation in with a unique number. the health record d. Uses an itemized list of patients past and present health problems
- Which of the following is true regard- The diseases to be reporter are established by ing the reporting of communicable dis- state law. eases? All states have a health department with a divi- a. They must be reported by the patient sion that is required to track and record commu- to the health department. nicable diseases. When a patient is diagnosed b. The diseases to be reported or estab- with one of the diseases from the health de- lish by state law. partment's communicable disease list, the facili- c. The diseases to be reported or estab- ty must notify the state public health department. lished by HIPAA.
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system. Which of the following should ing as well as sharing data with external or- be the HIM director's first step in carry- ganizations for use in benchmarking and other ing out this responsibility? purposes. The HIM director should identify data content requirements for all areas of the organi- a. Call the EHR vendor and ask to review zation to ensure the data content standards are the system's data dictionary b. Identify data content requirements for all areas of the organization c. Schedule a meeting with all Depart- ment directors to get their input d. Contact CMS to determine what data sets required to be collected
- A health data analyst has been asked to compile a report of the percentage of patients who had a Baseline throm- met. Medication administration Record and Clinical Laboratory reports boplastin time (PTT) test performed pri- Clinical^ laboratory^ reports^ should^ be reviewed to or to receiving heparin. What clinical reports in the health record would the health data analyst need to consult in order to prepare for this report? a. Physician progress notes and med- ication record b. Nursing and physician progress
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notes c. Medication administration record and Clinical Laboratory reports d. Physician orders in Clinical Laborato- ry reports 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 per- formed.
- Master patient index
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nections between two systems. For example, mapping two ditterent coding systems to show the equivalent codes allows for data initially cap- tured for one purpose to be translated and used for another purpose. 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.
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c. Physical examination d. Progress notes
- The MPI manager has identified a pat- tern of duplicate health record num- bers from the specimen processing area of the hospital. After spending time merging the patient information Laboratory As the HIM department merges two dupli- cates together, the source system (laboratory) also must be corrected. This creates new chal- and correcting the duplicates in the pa- lenges^ for^ organization^ becaue^ merge function- (^) tient information system, the MPI man- ality could be ditterent in each system or module, (^) ager needs to notify which department which in turn creates data redundancy. Address- to correct the source system data? a. Laboratory b. Radiology c. Quality management d. Registration
- 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 ing ongoing errors within the MPI means an established quality measurement and mainte- nance program is crucial to the future of health- care. UACDS: Uniform Ambulatory Care Data Set The Uniform Ambulatory Care Data Set data characteristics include patient-specific items for ensure (^) that all federally recommended outpatient care.
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To comply with the Joint Commission Review each patient's health record concurrently standards, the HIM director wants to be to make sure that history and physicals are pre- sure that history and physical examina- sent tions are documented in the patient's health record no later than 24 hours The quantitative analysis or record content re- after admission. Which of the following view^ can^ be^ handled^ in^ a^ number^ of^ ways. Some would be the best way to ensure the completeness of the health record? a. Establish a process to review health records immediately on discharge b. Review each patient's health record concurrently to make sure the history and physicals are present c. Retrospectively review each patient's health record to make sure that history and physicals are present d. Write a memorandum to all Physi- cians relating to the joint commission requirements for documenting history and physical examinations
- The HIM director is having difficulty with the emergency services on- call physicians completing their health records. Three deficiency notices are sent to the physicians including an ini- tial notice, a second reminder, and a fi- nal notification. Which of the following would be the best first step in trying to rectify the current situation?
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Acute-care facilities conduct record review on a continuing basis during a patient's hospital stay. Using this methid, personnel from the HIM de- partment go to the nursing unit daily (or period- ically) to review each patient's record. This type of process is usually referred to as a concurrent review because review occurs concurrently with the patient's stay in the hospital. Consult the physician in charge of the on-call doctors for suggestions on how to improve re- sponse to the current notices A coding manager or physician champion should present documentation issues to educate the medical statt. General areas of concern re- garding documentation should be included.
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organizations that participate in the Medicare program. In other words, participating organi- zations receive federal funds from the Medicare program for services provided to patients and thus must follow the Medicare Conditions of Par- ticipation. Delinquent record When an incomplete record is not rectified with- in a specific number of days as indicated in the medical statt rules and regulations, the record is considered to be a delinquent record. The HIM department monitors the deliquent record rate
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c. Pending record d. Illegal record
- How do accreditation organizations such as the Joint Commission use the health record? a. To serve as a source for case study information very closely to ensure compliance with accredit- ing standards. To determine whether standards of care or being that Every Participating healthcare organization is subject to a periodic accreditation survey. Sur- veyors visit each facility and compare its pro- b. To determine whether the documen- grams, policies and procedures to a prepub- tation supports the providers claim for reimbursement c. To provide Health Care Services d. To determine whether standards of care are being met
- Which of the following specialized patient assessment tools must be used by Medicare certified Homecare providers? a. Minimum data set for long- term care b. Outcomes and assessment informa- tion set c. Patient assessment instrument d. Resident assessment protocol
- Before healthcare organizations can provide services, they usually must ob- tain by government entities such as the state or county in which they are
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located. a. Accreditation b. Certification c. Licensure d. Permission
- The following descriptors about the data element ADMISSION_DATE are in- cluded in a data dictionary: definition: date patient admitted to the hospital; data type: date ; field length: 15; re- quired field: yes; default value: none; template: none. For this data element, data Integrity would be better assured if: a. The template was defined b. The datatype was numeric c. The field was not required d. The field link was longer
- In designing an input screen for an EHR, which of the following would be best to capture discrete data? a. Speech recognition b. Drop down menus c. Natural language processing d. Document Imaging
- A medical group practice has contract- ed with an HIM professional to define
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or remain in operation within their states. To continue licensure, organizations must demon- strate their knowledge of, and compliance with, documentation regulations. 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 tem- plate is to ensure data integrity upon data entry. Drop down menus Structured data are data that are able to read and interpreted by a computer. Examples of structured data include check boxes, drop-down boxes, and radio buttons. Develop a list of statutes, regulations, rules, and guidelines that contain requirements attecting
