Exam 5: Health Data Content and Structures

It is said that data and the manner in which it is managed are driving forces in health care today. Discuss why this statement is true and what it is based on?

What type of progress notes are organized by the SOAP approach?

Serial Unit Numbering System assigns a new number to the same patient regardless of the number of times the patient is admitted or registered at the same health care facility.

Strict alphabetical systems work best with large groups of health records; groups of health records of 2,000 or more make the use of alphabetical systems problematic.

_________ refers to the act or process of ensuring the entry in the record for both accuracy and authorship.

Match the terms with the best description. -health record has separate sections/areas for lab, physical therapy, provider progress notes, etc.

Abstracting selected data elements is often used for educational material for staff and students.

Match the type of analysis to the examples given. -determining if all test results are reported in the record to support a particular diagnosis

Which of the following terms refers to raw facts and figures?

How long must HIPAA compliance records be retained?

A health care provider administers the incorrect dose to a patient. The correct form to complete regarding this error is a(an) ____________________ ____________________.

Third-party payers in the private sector rely only on the data found in the health record to document the course of the patient's illness and treatment.

A master patient index (MPI) is a listing or database of all the patients treated by a health care facility, indexed according to an identification process.

The movement of data through a system and to those in need of it is referred to as what?

Match the characteristic of data quality with its definition. -data are collected when necessary

List two advantages of an electronic health record (EHR) over a paper-based health record.

A patient is taken to the emergency room with the end stages of colon cancer and dies within 24 hours of arrival. In which registry(ies) would this patient potentially be listed?

Match the type of analysis to the examples given. -some of the progress notes are missing from a health record

A patient requests to see her health care record, but the facility declines the patient's request. Which of the following statements best applies to this scenario?

Which term indicates concentrating on the quality of the record content and not the quality of the medical care rendered to the patient?