Module 5 Introduction to Data Quality

Question 1

HIM professionals are one of the main collectors of health information and therefore have the responsibility to maintain ____

Answer 1

high quality data

Question 2

Name some data collection trends.

Answer 2

1. increasing amounts of data are being collected and used for a variety of purposes
2. conversion of paper > hybrid > EHR
3. adding data collection from more settings like home care, long term care
4. standardization

Question 3

As we move toward a fully integrated, pan-Canadian EHR, the importance of ___ has become more evident

Answer 3

standardization

Question 4

Standardization needs to be considered for which 4 factors?

Answer 4

1. systems
2. processes/methods
3. rules
4. timelines

Question 5

High quality data means data that is:

Answer 5

1. accurate
2. timely
3. complete
4. held to a high level of integrity

Question 6

ICD-10-CA/CCI were implemented in which years in Canada?

Answer 6

2001-2003

Question 7

When were ICD-10-CA and CCI implemented in Alberta?

Answer 7

2002-2003

Question 8

When is ICD-11 due to go to the WHO Assembly?

Answer 8

2017

Question 9

Name a future system trend.

Answer 9

computer assisted coding

Question 10

Who is using data collected?

Answer 10

CIHI, Insurance, education, research, funding, drug companies

Question 11

What are the impacts of poor quality data?

Answer 11

insurance denied, miss out on teaching and learning opportunities, impact funds

Question 12

What promotes data quality?

Answer 12

national coding standards, training/education sessions, use of abstraction and encoder systems

Question 13

______ systems have built in edits to ensure that the data entered fits the expected format of the field, falls within the acceptable range of values, and has a logical relationship to other fields

Answer 13

abstraction and encoder systems

Question 14

Done to determine the quality of coding in clinical and non-clinical information; helps to identify the sources of coding standardization and/or inaccuracy issues

Answer 14

reabstraction studies

Question 15

What is the purpose of reabstraction studies?

Answer 15

Not to place blame, but to identify possible data quality issues

Question 16

What are some causes of coding variations?

Answer 16

1. Misinterpretation of standards
2. Non-compliance with, or lack of knowledge of, the standards
3. Hospital or regional practices that negatively affect the data quality
4. Quality and completeness of chart documentation
5. Unintentional human error

Question 17

Verifies the accuracy and completeness of the record, and ensures the chart is in the correct facility-determined order

Answer 17

health record analysis

Question 18

What are the two main types of health record analysis?

Answer 18

quantitative and qualitative analysis

Question 19

The third type of health record analysis which should be met if the quantitative and qualitative analysis is completed accurately

Answer 19

legal analysis

Question 20

A detailed review of the health record, usually completed after a patient has been discharged from the facility

Answer 20

quantitative analysis

Question 21

Why is quantitative analysis done?

Answer 21

1. to verify the presence of required data
2. to ensure that reports have been authenticated and/or signed by the healthcare provider responsible for that form or entry

Question 22

If a chart isn’t complete, it is termed _____

Answer 22

delinquent record

Question 23

Delinquent records must be completed in the timeline set by the facility’s _____

Answer 23

bylaws

Question 24

Accreditation standards often require that delinquent records be completed within ___ days of discharge

Answer 24

14

Question 25

T or F. Failure to complete missing information may result in the physician having their admitting privileges suspended until the charts are complete.

Answer 25

T

Question 26

Once a physician completes the missing elements, the chart is ____ to ensure completion.

Answer 26

reanalyzed

Question 27

Most hospitals using paper-based health records will use _____ indicating any omissions placed at the front of the incomplete episode of care, indicating the responsible documenter, what and where the deficiencies are in the record, and the date and signature of the employee who performed the quantitative analysis.

Answer 27

pre-printed form

Question 28

Electronic Health Record programs will have a ____ procedure in the software

Answer 28

deficiency notification

Question 29

The professional analyzing the chart will open the chart to view it, and then create a ______ to note any missing signatures or documentation. Once the document is created, the physician receives a ______ when they log into the EHR

Answer 29

deficiencies document, deficiency message

Question 30

T or F. Physicians can either electronically sign or reject the deficiency

Answer 30

T

Question 31

A health record can meet the standards required for quantitative analysis, but this may not mean the documentation is _____ and _____

Answer 31

consistent and error-free

Question 32

Analysis that requires thorough knowledge of medical terminology, anatomy, and pathophysiology in order to identify inconsistences and refer them for review by the appropriate medical or clinical staff committee for follow-up.

Answer 32

qualitative analysis

Question 33

It is the role of the ___ to determine whether there is a true inconsistency, or if the documentation is sufficient in its current state.

Answer 33

committee

Question 34

T or F. Performing quantitative and qualitative analysis can be very labour-intensive, and therefore costly

Answer 34

T

Question 35

What is the current trend in quantitative/qualitative analysis?

Answer 35

Shifting the responsibility of ensuring documentation is complete to the healthcare providers.

Question 36

Pre-printed forms address which 6 main data elements?

Answer 36

1. omissions 2. who needs to complete the chart 3. what the deficiencies are 4. where the deficiencies are 5. date 6. signature of the employee who did the QA

Question 37

Incomplete charts are often filed in a separate area by either _____ or _____

Answer 37

provider name or chart number

Question 38

T or F> Once the provider has completed the charts they will go through quantitative analysis again to confirm omissions were completed; once confirmed the charts will be re-filed in the active area

Answer 38

T