Study Guide: Health Data Content and Structure

Which of the following requires hospitals to establish a medical record service and also requires the hospital to maintain a medical record for each inpatient and outpatient?

Medicare Conditions of Participation (CoP)

HIM professionals assure that accurate information is ready at the fingertips of professionals engaged in clinical care. The process of creating policies, processes, and procedures focusing on the management of information specifically related to patient care and operations of the healthcare organization is called __________________. 

data governance.

___________________________ has an average inpatient length of stay greater than 25 days. They typically provide care for patients who have clinically complex conditions.

Long Term Care Hospital 

Which is an example of clinical data?

Discharge summary

The HIM director has received a written document that requires her to appear in court and bring any and all records on a patient. The document that she received is called a

subpoena duces tecum.

Which of the following is used for the collection, storage, retrieval, analysis, and dissemination of information on individuals who have a particular disease?

Registry

What may be grounds for termination from a professional practice experience site? 

Breach of confidentiality 

Which coding system is used in the United States to collect information about diseases and injuries and to classify diagnoses and procedures?

ICD-10-CM/ICD-10-PCS

An example of administrative application of the electronic health record would be ___________.

patient scheduling

The QI department needs to obtain a list of patients discharged within the last three months with a diagnosis of diverticulitis. This information can be obtained from the:

Disease index.

What agency is responsible for maintaining official vital statistics? 

National Center for Health Statistics

Which committee ensures patient safety by analyzing trends of incidents and establishing priorities for dealing with high-risk areas?

Risk management

Sunny Valley Hospital has adopted the following medical record maintenance guidelines:

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1.Only electronic entries will be authenticated by the author.

2.Records will be retained for at least one year.

3.Records will contain justification for admission and continued hospitalization

4.Original records can be released with patient consent.

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Which guideline aligns with Medicare Conditions of Participation?

3

The minimum core data set collected on individual hospital discharges for the Medicare and Medicaid programs is called the

Uniform Hospital Discharge Data Set

A consultation report, history and physical exam, and operative records are all examples of what type of data? 

Clinical

An example of a clinical application of the electronic health record would be _________________.

pharmacy 

A physician writes the following note: “Onset of contractions started at 4:00 a.m. Patient refused medications. Normal presentation. Outcome of delivery: single male infant.” This information would be documented as part of the

Labor and delivery record.

In 1991 the Institutes of Medicine suggested that electronic medical records should include nine features. Later, in 2009, the government passed the HITECH Act which _______________________.

provided incentives to adopt EHR systems

The federal organization that supports research designed to improve the outcomes and quality of health care, reduce costs, and address patient safety and medical errors is called ______________________________________.  

Agency for Healthcare Research and Quality  (AHRQ)  

The ultimate goal of a regional health information organization (RHIO) is to

allow health care providers the opportunity to access patient information that was generated at other locations.

The process of advising a patient about treatment options is known as

Informed consent.

Dr. Johns is an unlicensed resident who performed a history and physical examination on Susie Smart and also dictated the report. Dr. Blake is Susie’s attending physician. Who must sign the history and physical?

Dr. Johns must sign the report first and then Dr. Blake must countersign.

The National Hospital Quality Measures are standardized measures that are a created in collaboration between The Joint Commision and _______________. 

CMS

Which of the following are quality issues present in MPI systems? Check all that apply. 

Typographical errors, outdated demographic information, incorrect names, duplicates, overlays, overlaps

Authentication of a patient record means that an entry is signed by which of the following? 

The author

What professional organization establishes standards for health information management educational programs?

Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)

Which of the following is required by Medicare Conditions of Participation to document the hospitalization outcome, case disposition, and follow-up provisions?

Discharge summary

Which index must be retained permanently?

Master patient index

Which of the following include the purpose(s) for the use of secondary data?

all of the answers are correct

A nursing home administrator publishes the following advertisement: “Seeking a health care professional who has the ability to coordinate a program to ensure superior patient care, monitor and improve patient outcomes, monitor facility compliance with accreditation and regulatory standards, and coordinate preparation for surveys.” The job title for this professional would be

Quality manager.

Which index refers to the organized listing of specific codes such as ICD-10-PCS or CPT for procedures or operations performed in healthcare?

procedure index

The Joint Commission requires that patient records be completed within how many days after a patient is discharged?

30

Which of the following records consists of a database, problem list, initial plan, and progress notes?

Problem-oriented

Which of the following is an ethical obligation of a health information management professional?

Safeguarding privacy 

There is a life cycle of a health information system. That cycle is ____________________________.

Development – Testing – Operation - Obsolescence.

Who is responsible for documenting care and treatment to prove that patient care was provided?

Health care providers

 Sally Jones analyzes patient records and identifies several records without final diagnoses and procedures recorded on the face sheet. The type of analysis she performed is

Qualitative

Which of the following organizations focuses on standards of clinical information used in medical organizations, such as hospitals and physician offices?

American Health Information Management Association (AHIMA)

A patient is admitted for congestive heart failure and hypertension. During the admission, the patient is also treated for uncontrolled diabetes. The uncontrolled diabetes is a

Comorbidity.

 A sender’s name typed at the end of an email, a personal identification number, and a digitized image of a handwritten signature are all examples of what type of authentication method?  

Electronic signatures 

What record format maintains reports according to the source of documentation?   

Source-oriented record

Dr. Jones is the attending physician for a patient who was admitted for colitis. The patient experiences chest pain during her hospitalization.. Dr. Jones asks Dr. Heart, a cardiologist, to evaluate the patient’s chest pain. Dr. Heart would document his examination of the patient, pertinent findings, recommendations, and opinions on the

Consultation report

Problem Number

Diagnosis

Date of Onset

Date Resolved

1

Hypertension

12/05/XX

2

Diabetes

1/3/XX

3

Urinary Tract Infection

2/25/XX

3/10/XX

4

Respiratory Infection

4/5/XX

4/15/XX

The above information would be recorded as part of a

Problem list

Which hospital department directs the facility-wide program that monitors standards of conduct, implements sanctions for noncompliance, and maintains a confidential integrity hot line?

Compliance

A patient was admitted to Sunny Valley Hospital on January 22 for pneumonia. The history and physical examination (H&PE) were placed on the record January 24. Which of the following statements is true, based on Joint Commission standards?

The record is not in compliance, as the H&PE needs to be completed within 24 hours.

A health care professional who oversees the development, implementation, maintenance of, and adherence to the organization’s policies that cover the safeguarding of patient health information is called a

Privacy officer.

Who reviews health-related claims to determine whether the costs are reasonable and medically necessary?

Health insurance specialist

Medical staff members are granted clinical privileges by the ________________________.

governing board.

The AHIMA Code of Ethics applies to which of the following?

AHIMA members, CCHIIM certified non-members, and students

 Facilities that provide custodial care but do not have team members with medical training will often provide ______________ such as dressing, bathing, walking, and eating. 

ADL – Activities of Daily Living 

The ability of different information systems to access, exchange, and cooperatively use data across regional and even national boundaries in a seamless way is called ________________________. 

interoperability 

 An inventory by systems to document subjective symptoms stated by the patient is called ____________________:.

Review of systems

Per Joint Commission standards, all inpatient hospital records must be completed within ____ days after discharge, regardless of the storage media of the record.

30

What is the process of translating data into information?

Data analysis

Sunny Valley Hospital has an electronic health record system. The health information management (HIM) department has been asked by the quality management department to monitor the number of times that providers make corrections in patient documentation. Which of the following would provide information that can be used by the HIM department to monitor the electronic record transactions?

Audit trail

Which of the following is a secondary purpose of the patient record? 

To evaluate quality of patient care

In 1961 the Health Information and Management Systems was formed to improve interoperability of health systems. It has seen evolution over the years, with the more recent ________________________ which provides patients with full access to their health data. 

21st Century Cures Act 

 What organization was established to oversee all policies that impact an individual’s initial and ongoing certification?

Commission on Certification for Health Informatics and Information Management (CCHIIM)

Which of the following has as a purpose to restrict the ability of incompetent health care practitioners to move to another state without disclosure or discovery of previous medical malpractice payment or adverse action history?

National Practitioner Data Bank

A disease index organizes patient data according to

ICD-10-CM disease codes.

How do most facilities organize the patient record during inpatient hospitalization?

Reverse chronological date order 

Sunny Valley Hospital uses the SOAP structure to document patient information. In which section would observations about the patient be documented? 

Objective

Medicare Conditions of Participation requires a final diagnosis with completion of medical records within _____ days following patient discharge. 

30

Which of the following encourages the reporting of health care mistakes to patient safety organizations by making the reports confidential and providing a shield from their use in civil and criminal proceedings?

Patient Safety and Quality Improvement

A healthcare staff member is working to transition the health information management (HIM) department from a paper system to an electronic system. Currently, each patient’s record has a paper history and physical, operative report, and discharge summary, while the progress notes and medication administration records are maintained in an electronic system. This is known as a(n)

hybrid record.

Implementation of healthcare information systems requires  

testing that the system works as it was intended 

Which of the following option(s) indicate the purpose of the health record? 

All of the answers are correct

Ancillary services include ____________________________________________________________.

Laboratory, physical therapy, and other diagnostic and therapeutics

Which of the following facilitates communication and continuity of care between health care team members?

Progress notes

Ancillary reports should be filed in the patient’s records as soon as an interpretation has been made. When does this usually occur?

Within 24 hours