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Terms in this set (100)
A critical early step in designing an EHR is to develop a(n) __ __ in which the characteristics of each data element are defined.
Once hospital discharge abstract systems were developed and their ability to provide comparative data to hospitals was established, it became necessary to develop ___ __.
uniform data definitions
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 ___ ___ ___.
A RHIT 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 ____.
True or false: Common healthcare data sets 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.
What filing system is being used if these numbers are health records of three records filed together: 36-45-99; 37-45-99; 38-45-99
True or False: the MPI is necessary to physically locate records within the paper based storage system for alphabetical systems.
The RHIT supervisor for the filing and retrieval section of the clinic is developing a staffing schedule for the year. The clinic is open 260 days a year and has an average of 600 clinic visits per day. The standard for filing records is 60 per hour. The standard for retrieval of records is 40 per hour. How many filing hours will be required daily to retrieve and file records for each clinic day?
unit numbering system
In what type of filing system are all encounters or patient visits filed or linked together?
True or false: A disadvantage of alphabetical filing is the uneven expansion of file shelves
What is a request from a clinical area to check out a health record called?
MS-DRG triples, pairs and singles
In analyzing the reason for changes in hospital's Medicare case-mix index over time, the analyst should start with that level of detail?
What is the tool that is usually used to track health records that have been removed from their permanent storage locations?
What is the term that is used to mean ensuring that data are not altered during transmission across a network or during storage?
What filing method is considered the most efficient?
recommend common data elements to be collected in health records
The primary purpose of a minimum data set in healthcare is to..
In LTC, the resident's care plan is based on data collected in the ___.
tasks that need to be performed in a specific sequence
Incorporating a workflow function in an electronic information system would help support...
An audit of a hospital's electronic health system shows that diagnostic codes are not being reported at the correct level of detail. This indicates a problem with __ __.
core data elements
Each of the three dimensions of information defined by the National Health Information Network contains specific recommendations for ___ __ __.
national health information network
NHIN stands for..
personal, provider, community
What are the three dimensions of information?
continuity of care record
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...
The home health perspective payment system uses the ____ data set for patient assessments.
The data set designed to organize data for public release about the outcomes of care is ___.
What allows a user to insert, update, delete, and query data from a database?
True of false: The master patient/population index includes patient identifiable information
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?
A notation for a hypertensive patient in a physician ambulatory care progress note reads, "Blood pressure adequately controlled." In which part of the problem oriented health record progress note would this be written?
What provides a standardized vocabulary for facilitating the development of computer-based patient records?
systematized nomenclature of medicine clinical terminology
SNOMED stands for..
What provides a system for classifying morbidity and mortality information for statistical purposes?
data represents facts, information represents meaning
What is the difference between data and information?
structure and content
Information standards that provide clear descriptors of data elements to be included in computer-based patient record systems are called __ __ __ standards.
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?
Mrs. Smith's admitting data indicates that her birth date is 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 record?
What is used to plot the points for two variables that may be related to each other in some way?
availability to a number of providers at the same time
What is a primary weakness of the paper-based health record?...
True or false: Invoice and services is an element is a component of most patient records.
True or false: Data accountability is a characteristic of high quality healthcare data.
A numerical measurement carried out to the appropriate decimal place is an example of __ ___.
True or false: Document patient care delivery is a primary purpose of the health record.
When data includes all required elements it is called ___ ___.
When data is easy to obtain it is called ___ ___.
In which department or unit is the health record number typically assigned?
Where would this be found: " 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"
medical laboratory report
Where would this be found:"CBC: WBC 12.0, RBC 4.65, HGB 14.8, HCT 43.3, MCV 93"
Who is responsible for the discharge summary?
Who is responsible for the medication record?
True or false: Admitting diagnosis is an example of clinical data
Where would this be found: "HEENT: reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds."
A hospital is concerned about the difficulty of retrieving records because some are stored on paper and some electronically. What would be the best solution for the hospital to ensure that all of the data for a patient are retrieved when needed?
Where would this be found:"Atrial fibrilation with rapid venticular response, left axis deviation, left bundle branch block"
social service note
Where would this be found:"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"
True or false: Patient's complete medical history is documented in an emergency care record
In a problem-oriented health record, problems are organized in __ __.
integrated health record
Documentation from various sources are integrated and arranged in strict chronological order
Represents documentation of the patient's current and past health status
Contains the physician's findings based on an examination of the patient
Its function is to document opinions about the patient's condition from the perspective of a physician not previously involved in patient care
Support for research is a ___ ___ of the health record.
Use of the health record by a clinician to facilitate quality patient care is considered a ___ __ of the health record.
american society for testing and measurement
In designing an electronic 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...
Messaging standards for electronic data interchange in healthcare have been developed by __.
The HIM department is planning to scan non electronic medical record documentation. The project includes scanning of health record documentation such as H&P, physician orders, operative reports, and nursing notes. What method would be the best to help HIM professionals monitor the completeness of health records during a patient's hospitalization?
Using a hospital discharge database, a physician does a study of diabetes comparing age of onset with response to a specific drug. The physician has gathered ___ from the database.
Two clerks are abstracting data for the same case for a registry. When their work is checked, discrepancies are found. What data quality component is lacking?
What term refers to the incidence of death?
Review of disease indexes, pathology reports, and radiation therapy reports is part of what function in the cancer registry?
american college of surgeons
Cancer registries receive approval as part of the facility cancer program from what agency?
National ambulatory medical care survey
What is a database from the National Health Care Survey that uses the patient health record as a data source?
What contains a list maintained in diagnosis code number order for patients discharged from a facility during a particular time period?
What contains a list maintained in procedure code number order for patients discharged from a facility during a particular time period?
A method used to identify patients who have been seen or treated in a facility for a particular disease or condition for inclusion in a registry.
The number assigned to each case as it is entered into a cancer registry
Include data on births, deaths, fetal deaths, marriages and divorces
increased use of automated data entry
The most prevalent trend in the collection of secondary databases is...
primary data source
Contains information about the patient that has been documented by the professionals who provided care to patient is considered a ___ __ __.
Suppose there are 6 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?
In a frequency distribution, the lowest value is 5 and the highest value is 20. What is the range?
What is the mean for the following frequency distribution: 10, 15, 20, 25, 25?
Suppose that 5 patients stayed in the hospital for a total of 27 days. What term would be used to describe the result of the calculation 27 divided by 5?
Given the numbers 47, 20, 11, 33, 30, 30, 35, and 50, what is the mode?
Mr.Jones was admitted to the hospital on March 21 and discharged on April 1. What was the length of stay for Mr. Jones?
The hospital discharged 9 patients on April 1. The LOS for each patient was: A) 1 day, B) 5 days, C) 3 days, D)3 days, E)8 days, F) 8 days, G) 8 days, H)9 days, I) 9 days. What was the median length of stay?
The hospital had 25 inpatient deaths, including newborns, for the month of June. The hospital performed 5 autopsies for the same period. What was the gross autopsy rate for the hospital for June?
If you want to display the parts of a whole in graphic form, what graphic technique would you use?
What rates describes the probability or risk of illness in a population over a period of time?
What 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 of the previous day?
inpatient service day
What unit of measure is used to indicate the services received by one inpatient in a 24-hour period?
gross hospital death rate
What rate is used to compare the number of inpatient deaths to the total number or inpatient deaths and discharges?
What term is used to describe the number of calendar days that a patient is hospitalized?
gross autopsy rate
What rate compares the number of autopsies performed on hospital inpatients to the total number of inpatient deaths for the same period of time?
What term is used for the number of inpatients present at any one time in a healthcare facility?
daily inpatient census
What is the official count of inpatients taken at midnight called?
Who uses data from the MDS for LTC?
True or false: Hospital administrator is an internal use of data
What is a research project in which new treatments and tests are investigated to determine whether they are safe and effective?
case mix index
The capture of secondary diagnoses that increase the incidence of CCs and MCCs at final coding may have an impact on __ ___ ___.
THIS SET IS OFTEN IN FOLDERS WITH...
HIT 200 - Ch 9 - Q & A
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