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data precision

the extent to which data have the values they are expected to have

data applications

the purposes for which data is collected

data comprehensiveness

the extent to which healthcare data are complete; data complete all required elements

data definition

the specific meaning of a heathcare related data element

data collection

the processes by which data are collected

data accuracy

the process by which data are free of identifiable errors; data are correct

data consistency

the extent to which data are reliable; that the dates of birth and all information is the same

data warehousing

the processes and systems by which data are archived

data accessiblity

the extent to which healthcare data are obtainable; data is easy to obtain

data currency

the extent to which data are up to date; making sure that data is input in record at time of occurence

data availability

the extent to which healthcare data are accessible whenever and whereever they are needed

data analysis

the processes by which data are translated into information that can be used for designated applications


the dates, number, image, symbol, letter and words that represent basic facts observations about people processes, measurements and conditions


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


the right of individuals to control access to their personal health information


the protection of privacy of individuals and the confidentality of health records

problem oriented health record format

a documentation approach in which the physician defines each clinical problem individually four components, the database, the problem list, initial plans and progress notes

integrated health record format

organizes all the paper forms in strict chronological order and mixes the forms created by different departments

source oriented health record format

organizes the information according to the patient care department that provided the care

clinical decision support

an information system that will assist physicians in diagnosing and treating patients.

government policy maker

an institutional user of the health record


the expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for it intended purpose

paper based records

do not have built in access control mechanism

data and information is not the same meaning

data is raw facts and figures and information is data converted into meaningful format

secondary purpose for health record

support for research; bioterrorism

primary purpose of the health record

use of a health record by a clinician to facilitate quality patient care is considered

How do accreditation organizations use the health record

to determine the standards are being met

how do research organization use the health record

to examine results of experimental protocals

attorneys for healthcare organizations use the health record to

protect the legal interest of the facility and healthcare providers

source oriented health record

our record has all lab report, progress reports, and so on filed together in separate sections of the health record

inaccurate data recorded in the health record

compromise quality patient care, contribute to incorrect assumptions by policy makers, invalidate research findings

computerized physician/ provider order entry

since we implemented a new technology, we eliminated lost orders and problems with legibility

patient care managers are

individual user of the health record

storing patient care documentation

is the most important function of the health record


healthcare info systems need to exchange info, this linkage between systems is called

data granularity

a numerical measurement carried out to the appropriate decimal place

are more stringent

EHR systems do not have the same access control requirements as paper based because they are more

who, what, where, when, how, and why

the health record is the storage place for data and information about the healthcare services to an individual patient. It documents the ______,______, ________, ______, _______.and _____ of patient care

what is the function of the health record

planning and managing care, evaluating adequacy and appropriateness of care, substaining reimbursement claims, protecting legal interests of both patient and healthcare provider

records of immunizations

the type of data not normally documented in the acute care health record

providing info about the patients insurance coverage

this is not a function of the discharge summary

patients consent to undergo treatment can be expressed in

by his or her submission to treatment, written agreement, verbal agreement

name of insurance company

an example of clinical data is progress notes, physician orders, and admission diagnosis, but what is not a type of clinical data


federal laws resulted in the new privacy regulations for healthcare organizations

operative report

a report that includes names of surgeon and assistants, date, duration, and description of the procedure and any specimens removed

a living will

an example of an advanced directive

Patients complete medical history

is not normally documented in a emergency care documentation

intermediate care facilities

which long term care facility is not governed by medicare

Outcomes and assessment information set

A specialized patient assessment tools must be used by Medicare certified home care providers

medicare conditions for coverage

regulations that are most commonly applied in end stage renal disease treatment

never obliterate data

what you should never do to data that incorrect in a medical record to make a correction

see accreditation from JOINT COMMISSION

acute care hospitals, psychiatric hospitals, home care providers, and ambulatory care organizations

the federal conditions of participation apply to which type of healthcare organization?

any organization that treats Medicare and medicaid patients

not a traditional health record format

process oriented health record

hybrid record

the health record format that is most commonly used by healthcare settings as they transition to EHR

data dictionaries

of the following which is not an example of data capture technology; bar code readers, data dictionaries, optical character readers, continuous voice recognition


the health record contains the statement as a SOAP note; the patient will be placed on IV antibiotics and blood cultures will be taken this is an example of

all of the above

which of the following factors should be considered when designing a data retrieval system for an EHR? presentation of data, quick search capablilities, need to know, and analytical capablities


the end result of a review process that shows voluntary compliance with guidelines of an external non profit organization


progress notes of physicians, nurses, therapists, and other authorized individuals would be found together in chronological sequence in a ______ paper record

chief complaint

which part of a medical history documents the nature and duration of the symptoms that caused a pt. to seek medical attention as stated in the patient own words

progress notes

creates a chronological report of the patients condition and response to treatment during a hospital stay

medical staff by laws

determines who can receive and transcribe verbal orders

problem list

which is not usually a component of the acute care patient records ; medical history, nurse assesment, problem list, progress notes

discharge summary

the attending physician is responsible for which of the following types of acute care documentation

medication record

a nurse is responsible for which of the following types of acute care documentation

admitting diagnosis

what is an example of clinical data? admitting diagnosis, data and time of admission, insurance information, health record number

operative report

the number of ligatures, sutures , packs, drains, and sponges used and specimens removed would be found in the: anesthesia report, progress notes, operative report, recovery room report

emergency care record

which type of specialized record includes care provided prior to arrival at a healthcare setting and contains the times and means of arrival? ambulatory care record, emergency care record, ambulatory surgery record,pediatric record

all of the above

documentation standards and guidelines are published by a variety of private and public organizations, including the ______. Joint commssion, american health information management association, national committee for quality assurance

can be accessed by multiple end users simultaneously

which of the following is true of computer based records? is usually supported by all healthcare providers, can be assessed by multiple end users simultaneously, has a clear definition and technological standards, permits minimal risks to healthcare privacy and security

medical history

which of the following represents documentation of the patients current and past health status?

physical exam

which of the following contains the physicians findings based on an examination of the patient

consultation report

documents opinions about the patients condition from the perspective of a physician not previously involved in the patients care

function of physicians orders

to document the physicians instructions to other parties involved providing care to the patient

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