Domain 1

Question 1

What two purposes do data sets serve in healthcare?

Answer 1

1. Identify data elements to be collected for each patient
2. Provide uniform definitions for common terms

Question 2

Use of uniform definitions

Answer 2

Ensures data collected from a variety of healthcare settings will share a standard definition.

Question 3

Standardizing data elements and definitions make it possible to?

Answer 3

Compare data collected at different facilities.

Question 4

What is the purpose of the UHDDS?

Answer 4

List and define a set of common, uniform data elements.

Question 5

Where are data elements collected from?

Answer 5

Health records of inpatient hospitals.

Question 6

Data elements are abstracted from health records and included in?

Answer 6

National databases

Question 7

Data Dictionary

Answer 7

A listing of all the data elements w/i a specific information system that defines ab individual data element, standard input of data element, and specific data length.

Question 8

Why should a data dictionary be implemented early by an org?

Answer 8

To support standardization within the EHR.

Question 9

Analysis, or review, of the health record is performed by?

Answer 9

HIM dept personnel

Question 10

Why is an analysis, or review, of the health record performed?

Answer 10

Determine completeness of the health record.

Question 11

Integrity is the security principle that protects data from

Answer 11

Inappropriate modification or corruption (unintentional or intentional modification/destruction)

Question 12

Data Set

Answer 12

Recommended list of data elements w/ defined and uniformed definitions relevant for particular use or are specific to a type of healthcare industry

Question 13

Unintentional modification or destruction

Answer 13

Wrong data destroyed
Wrong backup to restore data
Electrical fire destroys computer

Question 14

S of SOAP

Answer 14

Subjective entry
Relates significant info in patients words or from patients point of view

Question 15

Data granularity requires that the attributes and values of data be

Answer 15

defined at the correct level of detail for the intended use of the data

Question 16

Information

Answer 16

data combined to produce value

Question 17

CCD

Answer 17

core data set of relevant administrative, demographic, and clinical information elements about a patient’s health status and healthcare tx

Question 18

Why was the CCD created?

Answer 18

to help communicate the core data set info from one provider to another for referral, transfer, or discharge of patient

Question 19

OASIS is a standardized data set designed to gather data about

Answer 19

Medicare beneficiaries receiving services from a home health agency

Question 20

OASIS core data items are collected on all?

Answer 20

adult home health patients

Question 21

A of SOAP

Answer 21

Assessment
Professional conclusions from eval of S or O info

Question 22

The NCQA sponsors

Answer 22

HEDIS

Question 23

HEDIS is a set of standard performance measures designed to

Answer 23

provide healthcare purchases and consumers with info they need to compare performance of health care plans

Question 24

Data Consistency

Answer 24

data is reliable

Question 25

Reliable data does not change regardless of how many times / in how many ways they are?

Answer 25

Stored Processed or Displayed

Question 26

Data values are consistent when the value of any given data element is

Answer 26

the same across applications and systems

Question 27

The operative report describes the

Answer 27

surgical procedures performed on the patient

Question 28

The operative report should be written or dictated by the surgeon

Answer 28

immediately after surgery

Question 29

The operative report becomes part of the

Answer 29

health record

Question 30

Data and content standards are

Answer 30

clear guidelines for acceptable values for specified data fields

Question 31

The data collected by the MDS are used to

Answer 31

develop care plans for residents and document placement at appropriate level of care

Question 32

Data and content standards make it possible to

Answer 32

exchange health info using electronic networks

Question 33

The MDS provides a structured way to

Answer 33

organize resident info develop a resident care plan

Question 34

What are the primary purposes of the health record?

Answer 34

Patient care delivery Patient care management Patient care support services Financial/other admin processes Patient self-management