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which of the following is a secondary purpose of the health record?

To generate a report to be used in performance improvement

Which of the following is an institutional user of the health record?

Goverment policy maker

How do patient care managers & support staff use the data documented in the health record

To evaluate the performance of individual patient care providers & to determine the effectiveness of the services provided

Which of the definitions below best describes the concept of confidentiality?

The expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purposes.

Which of the following statements does not pertain to paper-based health records?

They have a built-in access control mechanism

Which of the following is an advantage offered by computer-based clinical decision support tools?

They give physicans instant access to pharmaceutical formularlies, referral databases, & reference literature.
They review structured electronic data & alert practitioners to out-of-range lab values or dangerous trends.
They recall relevant diagnostic criteria & treatment options on the basis of data in the health record & thus support physicians as they consider diagnostic & treatment alternatives

The hospital where I work is transitioning to the EHR. In the meantime, we have part of the health record electronic & part is still paper. This concept is known as?

Hybrid record

Critique this statement. Data & information means the same thing.

This is a false statement as data is raw facts & figures & information is data converted into a meaningful format.

Which of the following statements does not pertain to EHR's?

EHR's are filed in paper folders.

Which of the following is a secondary purpose of the health record?

Support for research

Use of the health record by a clinician to facilitate quality patient care is considered?

Primary purpose of the health record

Use of the health records to monitor bioterrorism activity is considered?

A secondary purpose of the health record

How do accreditation organizations use the health record?

To determine whether standards of care are being met

How do research organizations use the health record?

To examine results of experimental protocols

Attorneys for healthcare organizations use the health record to?

protect the legal intersts of the facility & its healthcare providers

Our record has all of the lab filed together, all of the progress note filed together, & so on. What format are we using?

Source oriented health record

Inaccurate data recorded in the health record could?

*Compromise quality patient care
*Contribute to incorrect assumputions of policy makers
*Invalidate research findings

The term used to describe expected data values is?

Data precision

Protections of healthcare information from damage, loss, & unauthorized alteration is also known as?

Security

Since we implemented a new technology, we have eliminated lost orders & problems with legibility. What technology are we using?

Computerized physician/provider order entry

The paper-based health record format that organized all forms in chronological order is known as?

The integrated-health record

Critique this statement. The health record documents services provided by allied health professionals & the patients family.

This is a true statement?
This is a false statement as the health record documents the care provided by healthcare professionals?

An individuals right to control access to his/her personal information is known as?

Privacy

When all required data elements are included in the health record, the quality characteristic for is met?

Data comprehensiveness

Critique this statement. Pateint care managers are individual users of health records.

This is a true statement.

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

Committee on Vital and Health Statistics

The primary purpose of a minimum data set in healthcare is to:

Recommend common data elements to be collected in health records.

Data that are collected on large populations of individuals and stored in databases are referred to as:

Aggregate data.

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

Uniform Hospital Discharge Data Set.

Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for:

Performance improvement programs.

A National Health Information Network is:

A network of networks.

Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallus valgus) is one purpose of:

Vocabulary standards.

The federal law that directed the Secretary of Health and Human Services to develop healthcare standards governing electronic data interchange and data security is the:

Health Insurance Portability and Accountability Act of 1996.

The number that has been proposed for use as a unique patient identification number but is controversial because of confidentiality and privacy concerns is the:

SSN.

Most healthcare informatics standards have been implemented by:

Consensus.

A critical early step in designing an EHR is to develop a(n) ___ in which the characteristics of each data element are defined.

Data dictionary.

According to the UHDDS definition, ethnicity should be recorded on a patient record as:

Hispanic, non-Hispanic, unknown.

Mary Smith, RHIA has been asked to work on the development of a hospital trauma data registry. Which of the following data sets would be most helpful in developing this registry?

DEEDS.

While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on:

Reason for encounter.

In long term care, the resident's care plan is based on data collected in the:

MDS, v. 2.0.

Reimbursement for home health services in dependent of data collected from:

OASIS.

A consumer interested in comparing the performance of health plans should review data from:

HEDIS.

I need a standard that allows data to be transferred across the Internet. Which of the following is my choice?

XML.

Each of the three dimensions (personal, provider, community) of information defined by the National Health Information Infrastructure (NHII) contains specific recommendations for:

Core data elements.

A statewide cancer surveillance system is an example of which of the NHII dimensions?

Community.

In order to effectively transmit healthcare data between a provider and payer, both parties must adhere to which electronic data interchange standards?

X12N.

A radiology department is planning to develop a remote clinic and plans to transmit images for diagnostic purposes. The most important standards to implement in order to transmit images is:

DICOM.

A core data set developed by ASTM to communicate a patient's past and current health information as the patient's transitions from one care setting to another is:

Continuity of Care Record.

Laboratory data is successfully transmitted back and forth from Community Hospital to three local physician clinics. This successful transmission is dependent on which of the following standards?

LOINC.

As many private and public standards groups promulgate health informatics standards, the Office of the National Coordinator of Health Information Technology has been given responsibility for:

Harmonization of standards from multiple sources.

Which of the following indexes and databases includes patient-identifiable information?

Master Patient Index.

Which of the following is an external user of data?

Public health department.

Review of disease indexes, pathology reports, and radiation therapy reports is part of which function in the cancer registry?

Case finding.

What is the information identifying the patient (such as name, health record number, address, and telephone number) called?

Demographic data.

Cancer registries receive approval as part of the facility cancer program from the which of the following agencies?

American College of Surgeons.

Two clerks are abstracting data for a registry. When their work is checked, discrepancies are found. Which data quality component is lacking?

Reliability.

Which national database includes data on all discharged patients regardless of payer?

Healthcare Cost and Utilization Project.

What does an audit trail check for?

Unauthorized use of a system.

Which law requires the reporting of deaths and severe complications due to devices?

Safe Medical Device Act of 1990.

Which of the following is a database from the National Health Care Survey that uses the patient health record as a data source?

National Ambulatory Medical Care Survey.

Which of the following contains a list maintained in diagnosis code number order of patients discharged from a facility during a particular time period?

Disease index.

Which of the following contains a list maintained in procedure code number order of patients discharged from a facility during a particular time period?

Operation index.

Which of the following is a collection of secondary data related to patients with a specific diagnosis, condition, or procedures?

Disease registry.

Case findings is a method used to:

Identify patients who have been seen or treated in a facility for a particular disease or condition for inclusion in a registry.

In a cancer registry, the accession number:

Is the number assigned to each case as it is entered into a cancer registry.

A population based registry:

Includes information from more than one facility in a particular geopolitical area, such as a state or region.

Which of the following is made up of claims data from Medicare claims submitted by acute care hospitals and skilled nursing facilities?

MEDPAR.

The Medicare Provider Analysis and Review file is made up of:

Medicare claims from acute care hospitals and skilled nursing facilities.

Which database must a healthcare facility query as part of the credentialing process when a physician initially applies for medical staff privileges?

NPDB.

Vital statistics include data on:

Births, deaths, fetal deaths, marriages, and divorces.

Which of the following is a function of the health record?

- planning and managing care
- evaluating the adequacy and appropriateness of care
- substantiating reumbursement claims
- protecting the legal interests of both patient and provider

Which of the following clinical data elements is not usually documented in the acute care record?

Records of immunization.

Which of the following is not a function of the disharge summary?

Providing information about the patient's insurance coverage.

In which of the following ways can the patient's consent to undergo treatment be expressed?

- by their submission to treatment
- by written agreement
- by verbal agreement

Which of the following would not be considered clinical data?

Name of insurance company.

Which of the following federal laws resulted in the new privacy regulations for healthcare organizations?

The Health Insurance Portability and Accountability Act

Which of the following includes names of the surgeon and assistants, date, duration and description of the procedure and any specimens removed?

Operative report.

Which of the following is an example of an advance directive?

A living will.

Which of the following materials is not documented in an emergency care record?

Patient's complete medical history.

Which of the following types of facility is not governed by Medicare long-term care documentation standards?

assisted living facilities

Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers?

Outcomes and Assessment Information Set

Which regulations are most commonly applied in end stage renal disease treatment?

Medicare Conditions for Coverage

Which of the following statements is not true of the process that should be followed in making corrections in paper-based health record entries?

The incorrect information should be obliterated.

Which of the following types of healthcare facilities may seek accreditation from the Joint Commission ?

- acute care hospitals
- psychiatric hospitals
- home care providers
- ambulatory care providers

The federal Conditions of Participation apply to which type of healthcare organization?

Any organization that treats Medicare or Medicaid patients.

Which of the following is not a traditional health record format?

process-oriented health record

Which health record format is most commonly used by healthcare settings as they transition to electronic records?

hybrid records

Which of the following is not an example of a data capture technology?

data dictionaries

The health record contains the statement: The patient will be placed on IV antibiotics and blood cultures will be taken. This statement is:

plan

Which of the following factors should be considered when designing a data retrieval system for an EHR?

- presentation of data
- quick search capabilities
- need to know
- analytical capabilities

What is the end result of a review process that shows voluntary compliance with guidelines of an external, non-profit organization?

accreditation

Progress notes of physicians, nurses, therapists and other authorized individuals would be found together in chronological sequence in a(an) ____________ paper record.

Integrated.

Which part of a medical history documents the nature and duration of the
symptoms that caused a patient to seek medical attention as stated in that
patient's own words?

Chief complaint.

Which of the following creates a chronological report of the patient's condition and response to treatment during a hospital stay?

Progress notes.

of the following determines who can receive and transcribe verbal orders?

Medical staff by-laws.

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