C810 Pre-Assessment Foundations of Healthcare Data Management

A physician group is updating its electronic database system to allow patients to create profiles and provide access to necessary individuals. Patients have the opportunity to access their personal health information electronically from remote locations. The patients like being able to see the doctor's open times to coordinate their schedules before requesting an office visit.

Which component of the patient portal is the ability to see a doctor's availability?

A. Scheduling

B. Online Visits

C. Medication Tracking

D. Appointment Reminders

A. Scheduling

A patient is admitted to an acute care facility while on vacation, but records from his physician's office cannot be immediately obtained. The patient has difficulty remembering his insulin dosage, but he recalls being enrolled in a patient portal.

Where would information about the patient's insulin dosage be found within this portal?

A. Appointment history

B. Medication history

C. Laboratory results

D. Problem list

B. Medication history

Which form of review is conducted after a patient is discharged from an acute care facility in order to obtain information about trends and patterns of documentation?

A. Open-record review

B. Point-of-care review

C. Closed-record-review

D. Ongoing-record review

C. Closed-record-review

A hospital uses a filing system for permanent storage of paper-based health records. The records are filed according to a three-part number made up of two-digit pairs.

Which type of system is this?

A. Unit numbering system

B. Terminal-digit filing system

C. Serial-unit numbering system

D. Straight numeric filing system

B. Terminal-digit filing system

A patient goes to an emergency room complaining of chest pain and is released home four hours later.

Which type of documentation is required in this scenario?

A. Plan of care

B. Time of admission

C. Discharge orders

D. Mental assessment

C. Discharge orders

A patient is ready to leave the emergency room but will need discharge orders before leaving.

How should the discharge orders be communicated to this patient?

A. A nurse should issue the order verbally.

B. A physician should issue the order verbally.

C. A physician should issue the order in writing.

D. A nurse should issue the order in writing

C. A physician should issue the order in writing.

Which component of the medical record do the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation require to be completed no more than 30 days before or 24 hours after admission?

A. Focus charting

B. Progress notes

C. Discharge summary

D. History and physical

D. History and physical

Which type of consent is a patient asked to sign before undergoing a scheduled gallbladder surgery?

A. Implied consent

B. Informed consent

C. Consent to treatment

D. Notice of Privacy Practices

B. Informed consent

Where does a nurse document that a patient is given an oral dose of Coumadin 1 mg while hospitalized?

A. Nursing notes

B. Progress notes

C. Nursing flowsheet

D. Medication administration record

D. Medication administration record

Which person's signature must be included on a consent form?

A. Physician

B. Privacy officer

C.Nurse

D. Patient

D. Patient

In a physician's practice, a doctor is attempting to submit a claim to Medicare, but the system is experiencing an outage.

Which form should this doctor use to submit a paper claim?

A. Original documents should be maintained in the health record.

B. Deletions should be made in the health record by the HIM professional.

C. Blank spaces should be left for physician signatures in the progress notes.

D. Chart labeling should be used for patients with a psychiatric diagnosis, alcohol condition, or HIV-positive status.

A. Original documents should be maintained in the health record.

In which time frame should the history and physical be completed after a patient is admitted to an inpatient healthcare facility?

A. 48 hours prior to discharge

B. 72 hours prior to admission

C. No more than 30 days before or 24 hours after admission

D At the first point of contact with the admitting physician or other medical staff

C. No more than 30 days before or 24 hours after admission

Which type of information can be found in a physician's orders?

A. Chronological statements about a patient's response to treatment during a stay in a facility

B. Written or verbal requests for treatment, tests, procedures, and medications

C. Opinions of physicians with specialty training beyond general board certification, such as oncologists, cardiologists, or dermatologists

D. Updates after surgery that include findings of procedures performed, specimens removed, and the postoperative diagnosis

B. Written or verbal requests for treatment, tests, procedures, and medications

A nurse at a long-term care facility is documenting a comprehensive assessment into a patient's medical record.

What must the record include to meet Centers for Medicare and Medicaid Services (CMS) requirements?

A. Minimum Data Set (MDS)

B. Health Level Seven (HL7)

C. Outcomes and Assessment Information Set (OASIS)

D. Healthcare Effectiveness Data and Information Set (HEDIS)

A. Minimum Data Set (MDS)

A state hospital system is collecting information on inpatient discharges from hospitals in the central part of a state.

Which database should the hospital system use to collect this data?

A. Uniform Hospital Discharge Data Set (UHDDS)

B. Outcomes and Assessment Information Set (OASIS)

C. Drug and Alcohol Services Information System (DASIS)

D. Healthcare Effectiveness Data and Information Set (HEDIS)

A. Uniform Hospital Discharge Data Set (UHDDS)

Which data type is a cardiac catheterization examination note an example of?

A. Metadata

B. Structured data

C. Unstructured data

D. Structural metadata

C. Unstructured data

A paragraph in a physician's order specifies information about a patient's discharge.

Which type of data is described in this scenario?

A. Valid

B. Structured

C. Sorted

D. Unstructured

E. Metadata

D. Unstructured

Classify each scenario as using either structured data or unstructured data.

Answer options may be used more than once or not at all.

Select your answer from the pull-down list.

A. A nurse enters a patient's zip code, and the state is automatically populated.

B. A physical therapist chooses the Therapy tab in the emergency health record and writes treatment plan notes.

C. A nurse answers a question on an assessment screen in the emergency health record by clicking a radio button in front of a Yes or a No.

D. A nurse adds a description of a patient's problem to the clinical assessment field.

E. A physician adds a picture of a patient's wound to the patient's emergency health record.

A. Structured

B. Unstructured

C. Structured

D. Unstructured

E. Unstructured

A health information management(HIM) director and a chief information officer have been asked to update the data governance strategic plan for their healthcare system. In particular,they are working on standardizing data governance language across the healthcare system and ensuring that they meet data regulations and mandates.

Which information governance principle is described in this scenario?

A. Compliance

B. Disposition

C. Transparency

D. Accountability

A. Compliance

A hospital is informing the Infection Control Committee about the number of postoperative infections it had during a given time period.

Which principle for information governance is used in this scenario?

A. Accountability

B. Integrity

C. Availability

D. Transparency

D. Transparency

A health information manager is responsible for properly destroying records after the retention period has passed.

Which principle for information governance is described in this scenario?

A. Transparency

B. Compliance

C. Disposition

D. Integrity

C. Disposition

A communication plan is being developed to reduce mistrust and miscommunication in a healthcare setting.

In addition to open communication, which other principle for information governance must be considered when developing this plan?

A. Protection

B. Transparency

C. Accountability

D. Integrity

B. Transparency

A data governance steering committee is formed and tasked with developing the goals of a data governance program.

Which generally accepted record-keeping principle is described in this scenario?

A. Integrity

B. Protection

C. Transparency

D. Accountability

D. Accountability

A health information management(HIM) director has been informed of potential data security violations. The HIM director asks one of the health informatics analysts to work with the chief information officer to monitor the audit trails of the EHR to identify any violations.

Which generally accepted record-keeping principle is described in this scenario?

A. Protection

B. Disposition

C. Availability

D. Accountability

A. Protection

A chief information officer at a hospital is working to improve data security methodologies within the hospital's electronic health record (EHR). The chief information officer enlists the help of the hospital's health information management(HIM) director to help design and enforce the new data security policies, which include the utilization of a new token system to access the EHR.

Which information governance principle is described in this scenario?

A. Protection

B. Disposition

C. Transparency

D. Accountability

A. Protection

In a healthcare facility that still uses paper records, a physician is requesting a record to complete a discharge summary that is now 28 days past due. The record tracker states that the record has been sent to storage.

Which record-keeping principle applies to this scenario?

A. Accountability

B. Retention

C.Availability

D. Compliance

C.Availability

Which term refers to how policy makers, data owners, data stewards, and other stakeholders interact with each other?

A.Accountability

B. Data governance

C. Rules of engagement

D. Business intelligence

C. Rules of engagement

What does a stakeholder analysis of a data governance system identify?

A. Goals of the program

B. Qualifications of the data managers

C. Needs of those interested in the data

D. Measures to evaluate program effectiveness

C. Needs of those interested in the data

What is a best practice for data governance that should be incorporated into every program?

A. Establishing revenue cycle processes

B. Identifying subject matter experts

C. Specifying data quality requirements

D. Establishing organizational legal processes

C. Specifying data quality requirements

Which organization requires cancer statistics to be reported from central registries to the national organization responsible for cancer statistics?

A. Statewide Cancer Registry (SCR)

B. National Practitioner Data Bank (NPDB)

C. Centers for Disease Control and Prevention (CDC)

D. Centers for Medicare and Medicaid Services (CMS

C. Centers for Disease Control and Prevention (CDC)

Which organization requires reporting of medical malpractice payments, federal licensure and certification actions, and adverse clinical privileges actions?

A. Department of Public Health B. National Practitioner Data Bank (NPDB)

C. Centers for Disease Control and Prevention (CDC)

D. Centers for Medicare and Medicaid Services (CMS)

B. National Practitioner Data Bank (NPDB)

Which organization administers voluntary accreditation programs and provides deemed status to certified hospitals and other healthcare organizations?

A. The Joint Commission (TJC)

B. Council on Accreditation (COA)

C. American Osteopathic Association (AOA)

D. Commission on Accreditation of Rehabilitation Facilities (CARF)

A. The Joint Commission (TJC)

What is the name of the Centers for Medicare and Medicaid Services (CMS) external audit program that works to reduce Medicare improper payments?

A. HEAT

B. MACs

C. MICs

D. RACs

D. RACs

Which assessment do the Conditions of Participation require all home health agencies to electronically report?

A. OASIS

B. HIS

C. MDS

D. RAI

A. OASIS

To which organization must a sentinel event be reported?

A. Centers for Medicare and Medicaid Services

B. American Hospital Association

C. The Joint Commission

D. Office of Inspector General

C. The Joint Commission

Which model describes the information that flows to more than one regional clinical data repository (CDR) and requested records sent from one regional authority?

A. Hybrid

B. Direct

C. Federated

D. Centralized

C. Federated

Which HIE model supports uniformity of data, quick response times to queries, and consistency in data accessibility?

A. Decentralized

B. Centralized

C. Hybrid

D. Health record banking

B. Centralized

A local skilled nursing facility (SNF), hospital, and public health agency all participate in a health information exchange (HIE). The data is pushed from their facilities into one repository where they all have access to retrieve data when needed.

Which model is described in this scenario?

A. Hybrid

B. Decentralized

C. Health record banking

D. Centralized

D. Centralized

Which characteristic addresses the level of depth represented by data in a fact or dimension table in a data warehouse?

A. Accuracy

B. Timeliness

C. Relevancy

D. Granularity

D. Granularity

Which quality describes data that is unaffected when used across all applications and systems?

A. Accuracy

B. Granularity

C. Consistency

D. Comprehensiveness

C. Consistency

An HIM analyst is charged with reviewing abstracted information on opioid-related admissions from the hospital's disease index database. The analyst wants to make sure that the correct ICD-10 codes have been abstracted and pulled from the database.

Which data quality characteristic does this situation involve?

A. Accuracy

B. Consistency

C. Accessibility

D. Comprehensiveness

A. Accuracy

A health information management(HIM) director is analyzing the results of a survey that was conducted to ask physicians and nurses abouttheir satisfaction with the HIM department. The following table shows the satisfaction percentage scored for each question: 98% How often does the HIM staff answer your call within 3 rings? 79% How often are you able to receive old paper records for current patients in an acceptable time frame? 100%How often are the reports provided by the HIM staff correct and valid? 100%How often does the training provided by the HIM staff relate to the most recent regulations?

Which conclusion should the HIM director make based on this data?

A. The HIM staff needs additional training on telephone etiquette, and a time study should be done to ensure there is enough telephone staff.

B. The HIM supervisor should consider developing a more current physician training schedule.

C. The HIM staff needs additional training on the importance of accessibility of old paper records and needs help in brainstorming a better process.

D. The HIM director should consider attending professional development training for Excel and other reporting skills.

C. The HIM staff needs additional training on the importance of accessibility of old paper records and needs help in brainstorming a better process.

A health information management(HIM) director is auditing physician documentation and finds that 3% of the discharge summaries from the last six months were completed more than 30 days past patient.

Which data quality standard is an area of concern in this scenario?

A. Timeliness

B. Accuracy

C. Comprehensiveness

D. Precision

A. Timeliness

Once a year, members of the Disaster Planning Committee meet to conduct mock drills that satisfy staff training requirements as outlined in the organization's disaster plan.

What is the best practice for training staff on disaster protocol?

A. Use a one-time mock drill because disasters are unpredictable

B. Use mock drills involving key personnel within the organization

C. Arrange for off-site training accomplished through a simulation of a disaster

D. Arrange for continuous training through in-service programs and conducting mock drills

D. Arrange for continuous training through in-service programs and conducting mock drills

If a disaster affects a facility, how should damage to off-site records be prevented?

A. By locating off-site storage at a distance far enough away from the facility

B. By locating off-site storage close to the facility

C. By returning off-site records to the facility until the disaster passes

D. By backing up off-site records immediately

A. By locating off-site storage at a distance far enough away from the facility

Which security feature should be enabled on backup tapes as a best practice to prevent a data breach?

A. User access controls

B. Access tracking and auditing_____________________

C. Encryption

D. Decryption

C. Encryption

During a storm, an electronic health record (EHR) has crashed. Data systems are needed for the ongoing treatment of current patients.

Which quality standard is jeopardized in this disaster and should be addressed?

A. Precision

B. Timeliness

C. Definition

D. Granularity

B. Timeliness

During a storm, the operation of information systems and data preservation are threatened, triggering a disaster protocol.

Which disaster recovery planning process step should be taken in this situation?

A. Document results

B. Execute the continuity plan

C. Review existing security

D. Conduct an impact analysis

B. Execute the continuity plan

A hurricane has occurred and a hospital's health information clerk (HIM) clerk needs to relocate information systems to an alternate site.

Which plan should the HIM clerk reference to ensure that correct procedures are followed?

A. Disaster Recovery Plan

B. Information System Contingency Plan

C. Continuity of Operations

D. Plan Critical Infrastructure Protection Plan

A. Disaster Recovery Plan

An acute care facility is concerned with identity theft and wants to update policies to detect identity theft in day-to-day operations, take steps to prevent the crime, and mitigate its damage. Which prevention program element should the facility update?

A. Red Flags Rule

B. Contingency Plan

C. Privacy Rule

D. Security Rule

A. Red Flags Rule

Because the medical records of a newborn must be retained for seven years after the patient reaches the age of majority, it is important to be able to retain records for a long time and have rapid access to them.

Based on current technology, what is the most effective place for data to be stored?

A. Electronic health record (EHR)

B. CD-ROM

C. Paper files

D. Scanned files

A. Electronic health record (EHR)

Which method of disposal would cause compliance issues for records that have met their required retention?

A. Records that are burned once reaching their retention

B. Records that are shredded once reaching their retention

C.Records that are made unidentifiable once reaching their retention

D. Records that are trashed once reaching their retention

D. Records that are trashed once reaching their retention

An internal medicine physician practicing at one of three hospitals in town wants to determine whether to expand the scope of the office practice to patients under 16 years old through recruiting a pediatrician.

Which data source, in addition to the current number of active pediatricians in the community, is needed to decide to go forward?

A. Immunization logs

B. Nursery admission data

C. Nursery discharge data

D. Census and vital statistics data

D. Census and vital statistics data

A hospital's chief executive officer (CEO) notices a spike in complaints about a certain unit and wants to know the average number of patients admitted to that unit in order to monitor staff need.

Where should the CEO look for this data?

A. Master patient index

B. Daily census report

C. Case management records

D. Disease index

B. Daily census report

When an entry is made to a disease registry, an automatic format check ensures the data field for "Present on Admission" (POA) is completed.

Which principle of data stewardship is this an example of?

A. Establishing controls

B. Assigning accountability

C. Establishing usage rules

D. Assigning decision rights

A. Establishing controls

An HIM professional is completing the death clearance as part of the central cancer registry procedure for data collection. This information is required to be shared with the Centers for Disease Control and Prevention (CDC) to develop survivor statistics.

Which principle of data stewardship is being applied?

A. Integrity

B. Retention

C. Compliance

D. Accountability

C. Compliance

A health information management(HIM) director is writing a data dictionary for a new disease registry.

For which area is this HIM director being a data steward?

A. Subject matter

B. Data definition

C. Data production

D. Data usage

B. Data definition

A report is needed from a disease registry, but patients' names must be de-identified.

Which category of key principles and practices applies to this scenario?

A. Individual rights

B. Responsibility of health data steward

C. Security safeguards and controls

D. Accountability, enforcement, and remedies

B. Responsibility of health data steward

Aggregate data has been provided to external users.

Which type of data would this be considered?

A. Primary

B. Secondary

C. Administrative

D. Patient-identifiable

B. Secondary

A physician documents the information provided by a patient in the patient's chart.

Which type of data would this be considered?

A. Discrete

B. Primary

C. Secondary

D. Aggregate

B. Primary

Which web-based repository of reports contains information on medical malpractice payments and adverse actions related to healthcare providers?

A. MedPAR

B. Trauma Registry

C. National Library of Medicine D.NationalPractitioner Data Bank (NPDB)

D. National Practitioner Data Bank (NPDB)

Why would a credentialing officer access the National Practitioner Data Bank (NPDB)?

A. To assess a practitioner's financial status T

B. To determine a practitioner's salary requirements

C. To review a practitioner's professional credentials data

D. To evaluate a practitioner's emergency responsiveness data

C. To review a practitioner's professional credentials data

The clinical trials databases house data extracted from health records of patients from all around the country.

What is a key use of these databases?

A. Determine patients admitted by each facility

B. Determine waiting time for surgical care

C. Determine availability of medications

D. Determine effectiveness of alternate treatment methods

D. Determine effectiveness of alternate treatment methods

A family practice clinic in a rural community partnered with a cardiology clinic in a large city to provide real-time, web-based cardiology services. The clinic installed the necessary equipment to provide these services.

Which technology specifically supports patient-centered care for this situation?

A. Health information exchange (HIE)

B. Telehealth

C. Patient portal

D. Personal health record (PHR)

B. Telehealth

A local hospital wants to connect to other hospitals to facilitate access and retrieval of clinical data to provide safer, timelier, patient-centered care.

A. Health information exchange (HIE)

B. Patient portal

C. Patient-wearable devices

D. Personal health record (PHR)

A. Health information exchange (HIE)

A patient has been experiencing an abnormal heartbeat. The patient's physician would like to monitor the patient's heart rate remotely.

Which patient-centered technology is needed in this situation?

A. Patient portal

B. Patient-wearable device

C. point-of-care information system

D. Computerized physician order entry

B. Patient-wearable device

A patient is being seen by a physician. The patient describes the reason for the visit and the history of present illness in detail. The physician records notes electronically at the point of care.

Which technology supports point-of-service documentation for this visit?

A. Health information exchange (HIE)

B. Electronic health record (EHR)

C. Patient portal

D. Computerized physician order entery (CPOE)

B. Electronic health record (EHR)

A hospital wants to connect to a network that allows it to have access to the records of patients who are treated at other area hospitals within the region.

Which technology allows the hospital this access?

A. Health information exchange (HIE)

B. Electronic health record (EHR)

C. Patient portal

D. Biological monitoring system

A. Health information exchange (HIE)