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A core data set developed by ASTM 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

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 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:


A healthcare enterprise wants to analyze data from multiple computer systems across the organization to determine trends in patient care services. Which of the following would be the best application to perform this function?

Data warehouse CORRECT ANSWER

A hospital is concerned about the difficulty in retrieving health records for patient care and legal purposes. Some of its data are stored electronically while the remainder are stored on paper. The hospital knows it will be several years before it will be able to implement an entire EHR system and go paperless. Given this information, which of the following would be the best solution for the hospital to ensure that all of the data for a patient data are retrieved when needed?
Continue with current system
Implement a document scanning system for storage of the paper record
Implement a microfilm system for storage and retrieval of the paper records
Implement a document scanning system for the paper records and interface data created in the current EHR with the document scanning system.

Implement a document scanning system for the paper records and interface data created in the current EHR with the document scanning system.

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 records progress note would this be written?


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?


A nurse is responsible for which of the following types of acute-care documentation?

Medication record

A record is considered a primary data source when it:

Contains information about the patient that has been documented by the professionals who provided care to the patient

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