RHIT D1 Data Analysis and Management

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RHIT Practice Questions

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,
A critical early step in implementing the EHR is to develop a data dictionary

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

Data set,
These systems used databases compiled from aggregate data on all the patients discharged from a particular facility and compare uniform discharge data from one to other. This lead to developing data set or lists of recommended data elements with uniform definitions.

In healthcare, data sets serve two purposes. First is to identify data elements to be collected about each patient. The second is to:

Provide uniform data definitions UDD,
Data elements is data that should be collected for each patient. Data definitions is a common terms. The use of UDD ensures that data collected from a variety of healthcare settings will share a standard definition and makes it possible to compare the data collected.

A health information technician is responsible for designing a data collection form to collect data on patients in an acute-care hospital. The first resource that she should use is:

UHDDS,
Uniform Hospital Discharge Data Set is to list and define a set of common, uniform data elements.

Which of the following is NOT a characteristic of the common healthcare data sets such as UHDDS and UACDS

They provide a complete and exhaustive list of data elements that must be collected.

In a paper-based system, the completion of the chart is monitored in a special area of the HIM department called the __________ file.

Permanent

Incomplete record file is the area of the HIM department keep______ Health record.

Keep a deficiencies health record and deficiency slip.

In which of the systems are all encounters or patient visits filed or linked together? which patient receive only one time number when first visit.

Unit numbering system

In which system patient receive a new number each time he/she is encounters or registered?

Serial numbering system

What is a disadvantage of alphabetic filing?

Uneven expansion of file shelves or cabinets, it does not ensure a unique identifier, and time consuming to purge or clean out files for inactive storage.

What is call when request from a clinical or other area in the organization to charge out a specific health record. It could be in paper or electronic form.

It's call Requisition, which contained patient's name, record number, date of the request, date and time needed, requestor's name, and location for delivery.

How do you file record in an alphabetical system

File the record alphabetically by the last name, followed by alphabetical of first name, and then alphabetical order of the middle initial.

In analyzing the reason for changes in hospital's Medicare case-mix index over time, the analyst should start with which of the following levels of detail?

MS-DRG triples, pairs, and singles

what tool is use to track paper health records that have been removed from their permanent storage locations?

Outguides,
is usually made of strong colored vinyl with two plastic pockets that placed in the record location when the record is removed from the file.

What is the term that is used to mean ensuring that data are not altered during transmission across a network or during storage?

Integrity

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

Recommend common data elements to be collected in health records

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

MDS (Minimum Data Set)
The MDS data are used to develop a resident assessment protocol (RAP) summary for each resident.

Incorporating a workflow function in an electronic information system would help support:

Tasks that need to be performed in a specific sequence.
workflow has been added to EDMS (electronic document management system), often simultaneously or in a specific sequence tasks.

A healthcare enterprise wants to analyze data from multiple computer systems across the organization to determine trends in patient care services. what is the best application/applying to perform this function?

Data warehouse is a spacial type of databases that consolidating and storing data from various databases throughout the enterprise.

Each of the tree dimensions (personal, provider, and community) of information defined by the National Health information Network (NHIN) contains specific recommendation for:

Core data elements, to support the development of networked health information system

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 (such as referral, transfer or discharge of the patient) is:

Continuity of Care Record (CCR)
The standard of CCR is a core data set of relevant administrative, demographic, and clinical information elements about a patient's health status and healthcare treatment.

The home health (patient who are in medicare program) prospective payment system uses the ____ data set for patient assessments.

OASIS, The Outcome and Assessments Information Set.

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

HEDIS, The Health Plan Employer Data and Information Set is sponsored by the National Committee for Quality Assurance (NCQA).

Which of the following allow a user to insert, update, delete, and query data from a database?

SQL, which is called structured query language and used to store and retrieve data in relational databases.

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

MPI/population index, master patient index which is a permanent. It's a primary guide to locating pertinent demographic data about the patient such as name,record number, date of birth, gender, dates of encounter address, phone number, and attending physician for each visit.

A notation for a diabetic patient in a physician progress note reads: "Occasionally gets hungry. No insulin reactions, Says she is following her diabetic diet." In which part of a problem-oriented health record progress note would this be written?

Subjective, entry relates significant information in the patient's words of from the patient's point of view.

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

Assessment, Professional conclusions reached from evaluation of the subjective or objective information make up the assessment.

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

SNOMED CT-Systematized Nomenclature of Medicine Clinical Terminology. This standard vocabulary needed to facilitate or to make the indexing, storage, and retrieval of patient info in an EHR. It's the most comprehensive controlled vocabulary for coding the contents of the health record.

Information standards that provide clear descriptors, and uniform definitions of data elements to be included in computer-based patient record systems are called____ standards.

Structure and content, they specify the type of data to be collected in each data field and the attributes and values of each data field, all off which are captured in data dictionaries.

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 or data timeliness

Mrs. Smith's admitting data indicates that her birth date was March 21, 1948. On the discharge summary, Mrs. Smith's birth date is recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record?

Data Consistency is data are reliable.

Which of the following is a primary weakness of the paper-based health record?

Difficulty to provide a vailability to a number of providers at the same time.

Which of the following elements is not a component of most patient records?

Invoice for services

Which of the following is not a characteristic of high-quality healthcare data?

Data accountability

what is a characteristics of quality healthcare data?

data accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy, and timeliness.

Uniform Ambulatory Care data set UACDS is a data elements for Medicare and Medicaid outpatients are used in___

Every facility for Outpatient care such as clinic.

Patient care managers use the data documented in the health record to____

Evaluate patterns and trends of patient care. The take details from individual health records and then put all the info together in one place. On the basis of these combined aggregate data, the managers recommend changes to patient care processes, equipment, and services.

Community Hospital has more than 100 clinical databases. The Data Quality Committee is studying the comparability among the databases. The data elements and data definitions are catalogued for each database. What would be the next logical step to determine the degree of data comparability among the databases?

Select a representative set of data elements and track these across the databases to identify consistencies and differences. It's should have data quality characteristics including accuracy, accessibility, comprehensiveness/completeness, consistency, currency, definition, granularity, and timeliness.

What is a key characteristic of the problem-oriented health record?

Uses an itemized list of the patient's past and present medical problems such as social, psychological , and medical problems. Each problem is indexed with a unique number.

What is NOT a function of the discharge summary?

Providing information about the patient's insurance coverage

What is the function of the discharge summary?

Is a concise a/c of the patient's illness, course of treatment, response to treatment, and condition at the time the patient is discharge from the hospital, follow up care. It's provides an overview of the entire medical encounter.

The health record generally contains two types of data____

Clinical and administrative.

Clinical data contain___

patient's medical condition, diagnosis, and procedures performed.

Administrative data contain_____

The name of the insurance company.

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

Aggregate data, used to develop info about groups of patients, for example, data about all of the patients who suffered an acute myocardial infarction during a specific time period could be collected in a database help identify common characteristics that might predict the course of the disease or provide info about the most effective way to treat it.

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 for blood clot time) performed prior to receiving heparin(blood thinner's med). What clinical reports in the health record would the health data analysts need to consult in order to prepare this report?

Medication record and clinical laboratory reports

Community Hospital had 250 patients in the hospital at midnight on May 1. The hospital admitted 30 patients on MY 2. The hospital discharged 40 patients, including deaths on May 2. Two patient were both admitted and discharged on May 2. What was the total number of inpatient service days for May 2?

(250+30)-40+2=242.

Inpatient service day IPSD is

Is a number of inpatient service days for a 24 hour period is equal to the daily inpatient census, that is for one service day for each patient treated.

Daily inpatient census is equal to____

the number of inpatient service days provide for a single day.

The total number of inpatient service days can compiled daily, weekly, monthly, and annually. It can be divided by the total number of days in the period of interest to obtain the average daily inpatient census. PS newborns is calculate separate

Ex: Day one, daily inpatient census is 240, 253 for day two, and 237 for day three. The total number of inpatient service days for the three day period is 730 which is a total inpatient service. Then divided by three days, you will get average daily census which is 243.3

The total number of inpatient service days for adults and children for the week of May 1 is 1,729, and the total for newborns is 119. What is the average daily census for hospital inpatient for the week of May 1.

Average daily census of A&C is (1729/7)=247 and NBs (119-7)=17. The average daily census is 247+17=264.

An example of data collected by the Joint Commission for the ORYX initiatives is ____

[Intrahospital mortality data]]. The ORYX integrate outcomes and other performance measures into the accreditation process through data collection about specific core measures. The core measures are based on selected diagnoses/conditions such as diabetes mellitus, the outcomes of which can be improve by standardizing care.

Community Hospital conducted sample of 600 health record to determine the rate of filing accuracy. Nine were misfiles identified. What is the percentages of filing accuracy at the hospital.

9 out of 600 misfiled, so the percentage of misfile is 1.5 calculated {9/600*100}. The accuracy filing percentages is 100-1.5 = [98.5%]

What is numbering systems that best for maintaining the encounters of a patient together?

[Unit] The advantage is that all info, regardless of the number of encounters, can be filed or linked together.

A critical element of data retrieval planning is designing a____

[Screen layout] Results retrieval technologies is the screen layout that can be customized to the user's preference in many EHR systems.

Master patient index considered the authoritative key in locating of _____

[Health record], filing clerk searches the MPI by patient name, then clerk uses the health record number to locate the patient's health record folder w/in the filing system.

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

[Integrated health record] format organizes all the paper forms in strict chronological order and mixes the forms created by different departments.

There are three types of formats are commonly used in paper-based record system. _____

Source-oriented, Problem-oriented, and Integrated. The source-oriented health record format organizes the information according to the patient care department that provided the care. This format is used by most acute care hospitals. The problem-oriented health record format is a documentation approach in which the physician defines each clinical problem individually. Information about the problems is organized into four components: the database, the problem list, initial plans, and progress notes. The integrated health record format organizes all the paper forms in strict chronological order and mixes the forms created by different departments.

What is the retention concern with electronic health records?

[Durability] because of the electronic media issue relates to whether old media can be read using newer hardware with newer software. This make many organizations make new copies of their backups periodically to ensure their permanence and reflect changes in software.

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