Domain 1 Data Content, Structure, and Information Governance Flashcards
A new health information management (HIM) director has been asked by the hospital CIO to ensure data content standards are identified, understood, implemented, and managed for the hospital’s EHR system. Which of the following should be the HIM director’s first step in carrying out this responsibility?
a. Call the EHR vendor and ask to review the system’s data dictionary.
b. Identify data content requirements for all areas of the organization.
c. Schedule a meeting with all department directors to get their input.
d. Review CMS guidelines to determine what data sets are required to be collected.
Standardizing medical terminology to avoid differences in naming various health conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallux valgus) is one purpose of:
a. Content and structure standards
b. Security standard
c. Transaction standards
d. Vocabulary standards
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:
a. Data comprehensiveness
b. Data consistency
c. Data currency
d. Data granularity
Identify the documentation that records the attending physician’s assessment of the patient’s current health status.
a. Physical examination
b. Medical history
c. Progress notes
d. Discharge summary
Which of the following is a key characteristic 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
c. Provides electronic documentation in the health record
d. Uses an itemized list of the patient’s past and present health problems
A health record technician has been asked to review the discharge patient abstracting module of a proposed new electronic health record (EHR). Which of the following data sets would the technician consult to ensure the system collects all federally required discharge data elements for Medicare and Medicaid inpatients in an acute-care hospital?
a. CARF
b. DEEDS
c. UACDS
d. UHDDS
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?
a. Physician progress notes and medication record
b. Nursing and physician progress notes
c. Medication administration record and clinical laboratory reports
Which of the following is considered the authoritative resource in locating a health record?
a. Disease index
b. Master patient index
c. Patient directory
d. Patient registry
A family practitioner requests the opinion of a physician specialist who reviews the patient’s health record and examines the patient. In what type of report would the physician specialist record findings, impressions, and recommendations?
a. Consultation
b. Medical history
c. Physical examination
d. Progress notes
The master patient index (MPI) manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. The MPI manager merged the patient information and corrected the duplicates in the patient information system. After this merging process, which department should the MPI manager notify to correct the source system data?
a. Laboratory
b. Radiology
c. Quality Management
d. Registration
What type of analysis compares omitted clinical information received from external providers with the needed clinical information to make a correct diagnosis?
a. Risk management analysis
b. Qualitative analysis
c. Gap analysis
d. Document management analysis
To comply with the Joint Commission standards, the HIM director wants to ensure the history and physical examinations are documented in the patient’s health record no later than 24 hours after admission. Which of the following 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 ensure the history and physicals are present.
c. Retrospectively review each patient’s health record to ensure the history and physicals are present.
d. Write a memorandum to all physicians relating 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. Currently, three deficiency notices are sent to the physicians through the EHR system including an initial notice, a second reminder, and a final notification. Which of the following would be the best first step in trying to rectify the current situation?
a. Call the Joint Commission and notify them of noncompliant physicians.
b. Consult with the medical director who has authority over the on-call physicians for suggestions on how to improve response to the current notices.
c. Post the hospital policy in the emergency department.
d. Routinely send out a fourth notice to remind each physician of his or her documentation obligations.
Creekside Care, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to become certified for these programs?
a. Minimum Data Set
b. National Commission on Correctional Health Care
c. Medicare Conditions of Participation
d. Outcomes and Assessment Information Set
A health record with deficiencies that is not completed within the timeframe specified in the medical staff rules and regulations is called a(n):
a. Suspended record
b. Delinquent record
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
b. To determine whether the documentation supports the provider’s claim for reimbursement
c. To provide healthcare 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 home care providers?
a. Minimum data set for long-term care
b. Outcomes and Assessment Information Set
c. Patient assessment instrument
d. Resident assessment protocol
Before healthcare organizations can provide services, they usually must obtain this from government entities such as the state or county in which they are located.
a. Accreditation
b. Certification
c. Licensure
d. Permission
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:
a. The template was defined.
b. The data type was numeric.
c. The field was not required.
d. The field length was longer.
In designing an input screen for an EHR, which of the following would be best to capture structured data?
a. Speech recognition
b. Drop-down menus
c. Natural language processing
d. Document imaging
A medical group practice has contracted with an HIM professional to help define the practice’s designated record set. Which of the following should the HIM professional perform first to identify the components of the designated record set?
a. Develop a list of all data elements referencing patients that are included in both paper and electronic systems of the practice.
b. Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records.
c. Perform a quality check on all health record systems in the practice.
d. Develop a listing and categorize all information requests for health information over the past two years.
Hospital documentation related to the delivery of patient care such as health records, x-rays, laboratory reports, and consultation reports are owned:
a. By the hospital
b. By the patient
c. By the attending and consulting physician
d. Jointly by the hospital, physician, and patient
Copies of personal health records (PHRs) are considered part of the designated record set when:
a. Consulted by the provider to gain information on a consumer’s health history
b. Used by the organization to provide treatment
c. Used by the provider to obtain information on a consumer’s prescription history
d. Used by the organization to determine a consumer’s DNR status
Which of the following is a true statement about the content of the legal health record?
a. The legal health record contains only clinical data.
b. The legal health record may contain metadata.
c. The legal health record should not include email.
d. The legal health record should not include diagnostic images
