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Domain 1: Health Data Management

A critical early step in designing an EHR is to develop a _____ 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 Sets

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

provide uniform data definitions

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 he or she should use is:

UHDDS- Uniform Hospital Discharge Data Sets

Which of the following in 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.

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

HEDIS- Health Plan Employer Data and Information Set

The name of the government advisory group that makes proposals for improvement of basic data sets for health records and computer databases is:

National 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

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 programs are designed to collect data to be used for:

performance improvement programs.

The focus of outpatient data collection in the UACDS is on:

reason for encounter

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

MDS- Minimum Data Set

Reimbursement for home health services is dependent on data collected from:

OASIS- Outcome and Assessment Information Set

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

Core data elements

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

Continuity of Care Record

The home health prospective payment system uses the___?

OASIS- Outcome and Assessment Information Set

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

Department of Health and Human Services

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

HEDIS- Health Plan Employer Data and Information Set

OASIS data used to assess the ___ of home health services


Which of the following includes patient-identifiable information?

Master patient/population index

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 POMR progress note would this be written?


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


A notation for hypertension patient in a physicain ambulatory care progress note reads: "Contnue with Diuril, 500 mg once daily. Return visit in 2 weeks." In which part of a POMR progress note would this be written?


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


A specif set of terms that may be used in an EHR is referrred to as a:

Controlled vocabulary

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

Health Common Procedure Coding System

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

International Classification of Disease for Oncology, 3rd edition

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

Systematized Nomenclature of Medicine Clinical Terminology

Which of the following is a system for classifying morbidity and mortality information for statisical purposes?

International Classification of Diseases, 9th Revision, Clinical Modification

Which of the following is not a knowledge souce for users of the Unified Medical Language System?

Concept table

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