Domain 1 RHIT Question

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Questions covering domain 1

A critical early step in designing an EMR "electronic medical record " is to develop ______ in which the characteristics of each data element are defined.

Data Dictionary

Once hospital discharge abstract systems were developed and their ability to provide comparative data to hospitals was established, it became necessary to develop _____.

Data dictionary

A health information technician has been charged with the responsibility for designing a data collection form to be used on admission for a patient to the acute care hospital in which she works. The first resource that she should use is _______.

"UHDDS"
Uniform Hospital Discharge Data Set

In healthcare, data sets serves two purposes. The first is to identify data elements to be collected about each patient. The second is to _____?

Provide uniform data definitions

This is not a characteristic of the common healthcare data sets such as UHDDS "Uniform Hospital Discharge Data Set" and UACDS "Uniform Ambulatory Care Data Set"?

They do not define minimum data elements to be collected.

A corporation is evaluating several health plans for its benefits package. The data set that provides comparison information about health plan performance is _____?

"HEDIS"
Healthcare Effectiveness Data and Information Set

The name for the government agency that has led the development of basic data sets for health records and computer databases is _____?

"NCVHS"
National committee on Vital and Health Statistics

The primary purpose of a minimum data set "MDS" in healthcare is to _____?

Recommend common data elements to be collected in health records

The inpatient data set that has been incorporated into federal law and is required for Medicare reporting is the _____?

"UHDDS"
Uniform Hospital Discharge Data Set

Both HEDIS "Healthcare Effectiveness Data and Information Set" and the Joint Commisssion's "TJC" ORYX programs are designed to collect data to be used for the ______?

" P I P"
Performance improvement programs

In log-term care "LTC", the resident's care plan is based on data collected in the _____?

"MDS Version 2.0"
Minimum Data Set Version 2.0

While the focus of inpatient data collection in the UHDDS "Uniform Hospital Discharge Data Set is on principal diagnosis, the focus of outpatient data collection in the UACDS "Uniform Ambulatory Care Data Set" is on _____?

Reason for Encounter

Reimbursement for home health sevices is dependent of data collected from _____?

"OASIS"
Outcome and Assessment Information Set

Each of the three dimensions personal, provider, and community for information defined by the National Information Infrastructure "NHIT" contains specific recommendations for ______?

Core data elements

A core data set developed by ASTM "American Society for Testing and Materials" to communicate a patient's past and current health information as the patient transitions from one care setting to another is _____?

Continuity of care Record

The home health prospective payment system "HH PPS uses the _____ data set for patient assessments.

"OASIS"
Outcome and Assessment Information Set

The government agency most closely involved in the development of healthcare data sets and information standards is ______?

"NCHS"
National Centers for Health statistics

The data set designed to organize data for public release about the outcomes of care is ______?

"HEDIS"
Healthcare Effectiveness Data and Information Set

OASIS "Outcome and Assessment Information Set" data are used to assess the ____ of home health services.

Outcome

The indexes and databases that includes patient - identifiable information is?

Master patient/population index

A notation on a diabetic patient in a physician progress note reads. "Rarely gets hungry. No insulin reaction, Says she is following her diabetic diet." In what part of POMR "problem-Oriented Medical Record" progress note would this be written?

Subjective

A notation for a diabetic patient in a physician progress note reads; "FBS 110 mg%, urine sugar, no acetone," In which part of a POMR progress note would this notation be written?

Objective

A notation for a hypertensive patient in a physician ambulatory care progress note reads; "Continue with Diuril, 500 mgs once daily. Return visit in 2 weeks." In which part of a POMR progress note would this notation be written?

Assessment

A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled." In which part of a POMR progress note would this notation be written?

Assessment

The set of all terms that may be used in a language is referred to as a _____?

Vocabulary

Which of the following promotes uniform reporting and statistical data collection for medical procedures, supplies, products, and services?

"HCPCS"
Healthcare Common Procedure Coding System

Which of the following provides a detailed classification system for coding the histology, topography, and behavior for neoplasms?

"ICD-O-3 "
International Classification of Diseases for Oncology, Third Edition

Which of the following provides a standardized vocabulary for facilitating the development of computer-based records?

"HCPCS"
Healthcare Common Procedure Coding System

Which of the following provides a system for classifying morbidity and mortality information for statistical purposes?

"ICD-9-CM"
International Classification of Diseases, Ninth Revision, clinical Modification

This is not a knowledge source for users of the Unified Medical Language System "UMLS "?

Concept table

Nosology can be defined as the branch of medical science that deals with?

Classification of patients into groups

This classification manual is used exclusively for classifying cases of malignant diseases?

"ICD-O-3"
International Classification of Diseases for Oncology, Third Edition

This provides the most comperhensive controlled vocabulary for coding the content of a patient record?

"SNOMED CT"
Systematized Nomenclature of Medicine--Clinical Terms

This manual provides a set of codes used for collecting data about substance abuse and mental health disorders?

"DSM-IV-TR"
Diagnostic and Statistical Manual of Mental Disorders 4th Edition, Text Revision

Dr Jones entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missing from the progress note?

Data currency

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