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
What is the common characteristic of a healthcare data set such as UHDDS and
They define minimum data elements to be collected. They provide a frame work for data collection to which an individual facility can add data items. The federal government recommends, but does not mandate, implementation of most of the data sets.
Consider the following sequence of numbers. What filing system is being used if these numbers represent the health record numbers of three records filed together within the filing system? (36-45-99; 37-45-99; 38-45-99)
Terminal-Digit
In which system are all encounters or patient visits filed or linked together?
Unit numbering system
In analyzing the reason for changes in hospital's Medicare case-mix index over time, the analyst should start with the following levels of detail?
MS-DRG triples, pairs, and singles
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
Each of the three dimension (personal, provider and community) of information defined by the National Health Information Network (NHIN) contains specific recommendations for:
Core Data Element
A code data set developed by ASTM to communicate a patient's past and current health information as the patient transitions form one care setting to another is:
Continuity of Care Record
A notation for a diabetic patient in a physician progress note reads: "Occasionally gets hungry. No insulin reactions. Says she is following her diabetic dies". In which part of a problem-orient health record progress note would this be written?
Subjective
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
What provides a standardized vocabulary for facilitating the development of computer-based patient records?
Systematized Nomenclature of Medicine Clinical Terminology
What is used to plot the points for two variables that may be related to each other in some way?
Scatter diagram
What is a characteristic of high-quality healthcare data?
Data relevancy; Data currency, and Data consistency
What would be an example of data granularity?
A numerical measurement carried out to the appropriate decimal point.
Identify where the following information would be found in the acute-care record: "Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion:
Operative Report
The followings documented in an acute-care record: "Atrial fibrillation with rapid ventricular response, left axis deviation, left bundle branch block." In which of the following would this documentation appear.
Clinical Laboratory report
The following is documented in an acute-care record:" Spoke to the attending re: my assessment, Provided adoption and counseling information. Spoke to CPS re: referral. Case manager to meet with patient and family" In which of the following would this documentation appear?
Social Service note
In designing an electrical health record, one of the best resources to use in helping to define the content of the record as well as to standardize data definitions are standards promulgated by the content of the record as well as to standardize data definitions are standards promulgated by the :
American Society for Testing and Measurement
Using a hospital discharge database, a physician does a study of diabetes mellitus comparing age of onset with response to a specific drug regimen. The physician has gathered ___ from the database
Information
Two clerks are abstracting data for the same case for a registry. When their work is checked, discrepancies are found. Which data quality component is lacking?
Reliability
Review of disease indexes, pathology reports, and radiation therapy reports is part of which function in the cancer registry
Case-Finding
Cancer registries receive approval as part of the facility cancer program from which of the following agencies
American College of Surgeons
Which of the following is a database from the National Healthcare Survey that uses the patient heath record as a data source?
National Ambulatory Medical Care Survey
In a cancer registry, the accession number:
Is the number assigned to each case as it is entered into a cancer registry
The most prevalent trend in the collection of secondary database is :
Increased use of automated data entry
Suppose that there are six males and 14 females in a class of 20 students with the data reported as 3/1. What term could be used to describe the comparison?
Proportion
What best describes the difference between a hospital inpatient and a hospital outpatient?
Inpatient's receive room, board, and continuous nursing services in areas of the hospital where patients generally stay overnight; outpatients receive ambulatory diagnostic and therapeutic services
Community Hospital discharged nine patients on April 1. The length of stay for each of the patient was as follows: For patient A, 1 day; for patient B , 5 days; for patient C, 3 days; for patient D, 3 days; for patient E, 8 days; for patient F, 8 days; for patient G, 8 days; for patient H, 9 days; for patient I, 9 days. What was the median length of stay?
8 Days
Which rate describes the probability or risk of illness in populations over a period of time.
Incidence rate
Which term is used to describe the number of inpatients present at the census-taking time each day plus the number of inpatients who were both admitted and discharged after the census-taking time the previous day?
Daily Inpatient Census
Which Rate is used to compare the nubmer of inpatient deaths to the total number of inpatient deaths and discharges.
Gross hosptial death rate
Which of the following use data from the MDS for long-erm care?
Centers for Medicare and Medicaid Services