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7. HRSC 1 > Module 5 Introduction to Data Quality > Flashcards

Module 5 Introduction to Data Quality Flashcards

1
Q

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

A

high quality data

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2
Q

Name some data collection trends.

A
  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
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3
Q

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

A

standardization

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4
Q

Standardization needs to be considered for which 4 factors?

A
  1. systems
  2. processes/methods
  3. rules
  4. timelines
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5
Q

High quality data means data that is:

A
  1. accurate
  2. timely
  3. complete
  4. held to a high level of integrity
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6
Q

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

A

2001-2003

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7
Q

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

A

2002-2003

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8
Q

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

A

2017

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9
Q

Name a future system trend.

A

computer assisted coding

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10
Q

Who is using data collected?

A

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

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11
Q

What are the impacts of poor quality data?

A

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

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12
Q

What promotes data quality?

A

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

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13
Q

______ 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

A

abstraction and encoder systems

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14
Q

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

A

reabstraction studies

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15
Q

What is the purpose of reabstraction studies?

A

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

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16
Q

What are some causes of coding variations?

A
  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
17
Q

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

A

health record analysis

18
Q

What are the two main types of health record analysis?

A

quantitative and qualitative analysis

19
Q

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

A

legal analysis

20
Q

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

A

quantitative analysis

21
Q

Why is quantitative analysis done?

A
  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
22
Q

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

A

delinquent record

23
Q

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

A

bylaws

24
Q

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

A

14

25
Q

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

A

T

26
Q

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

A

reanalyzed

27
Q

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.

A

pre-printed form

28
Q

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

A

deficiency notification

29
Q

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

A

deficiencies document, deficiency message

30
Q

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

A

T

31
Q

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

A

consistent and error-free

32
Q

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.

A

qualitative analysis

33
Q

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

A

committee

34
Q

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

A

T

35
Q

What is the current trend in quantitative/qualitative analysis?

A

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

36
Q

Pre-printed forms address which 6 main data elements?

A
  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
37
Q

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

A

provider name or chart number

38
Q

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

A

T

7. HRSC 1 (7 decks)

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