Deck 5: Health Data Content and Structures

Question 1

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.

Answer 1

True

Question 2

When a health care facility goes bankrupt, the facility must maintain the records on-site until the retention period is met.

Answer 2

False

Question 3

Each data element is defined to the necessary level of detail.

Answer 3

True

Question 4

A data flow diagram displays how data movement is tracked.

Question 5

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.

Question 6

A discharge summary is a description of treatments rendered and procedures performed, including findings and results.

Question 7

Qualitative Analysis concentrates on what forms or data should be present in, but are missing from, the health record.

Question 8

Alphabetical systems are used with electronic health record systems and rely on the use of a patient's surname, first name, middle initial, and suffix to differentiate the storage of one patient's data from another patient's data.

Question 9

Unilateral data flow was the method used by many in the health information management profession during the first half of the 20th century.

Question 10

The integrity of the health record is supported by the activities of quantitative and qualitative analysis.

Question 11

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

Question 12

There are multiple registries that exist to serve health care needs. Some function at the local level and others at an international level.

Question 13

Authentication refers to possessing all parts or elements necessary to be considered whole or entire.

Question 14

An enterprise master patient index is when multiple health care facilities share the same master patient index.

Question 15

When a health care facility closes, the health care record retention criteria changes.

Question 16

The source-oriented health record is organized according to the "source" or department that provided the data.

Question 17

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

Question 18

The problem-oriented health record organizes data according to the patient's problems.

Question 19

A personal health record (PHR) is updated and maintained by the patient or the person responsible for the patient.

Question 20

Unit numbering systems are creating the potential for the same patient to receive two or more numbers, depending on the frequency of admissions to that facility.

Question 21

The abbreviation SOAP stands for

A) Subjective, Objective, Assessment, and Plan.
B) Subjective, Operation, Ancillary, and Protocol.
C) Subjective, Objective, Assessment, Protocol.
D) Subjective, Operation, Ancillary, and Plan.

Question 22

What is another name for a health record?

A) medical record
B) hospital chart
C) clinical record
D) all of the above

Question 23

In a large metropolitan health care facility, which type of record identification system would you expect to be used?

A) alphabetical
B) numeric
C) soundex
D) not enough information to make a determination

Question 24

Which of the following are components of a records management system?

A) data storage
B) retention
C) destruction
D) none of the above
E) all of the above

Question 25

Four concepts directly relating to the content of the health record are

A) authorship, authentication, timeliness, and completeness.
B) authorship, authentication, accuracy, and completeness.
C) authentication, accuracy, timeliness, and completeness.

Question 26

Data collection of a patient's personal and financial information is always collected at the bedside.

Question 27

How long must HIPAA compliance records be retained?

A) 2 years
B) 3 years
C) 5 years
D) 6 years

Question 28

Which of the following statements most accurately defines administrative data?

A) basic identification and financial data routinely collected on every patient
B) an ordered set of documents or a collection of data that contains a complete and accurate description of a patient's history, condition, diagnostic and therapeutic treatment, and the results of treatment
C) raw facts and figures
D) data collected and maintained related to the patient's health and course of treatment and care

Question 29

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.

Question 30

A storage choice that can serve as a bridge between a paper-based health record and an electronic health record is called

A) a bridge database
B) a serial-unit numbering system
C) a digital imaging system
D) none of the above

Question 31

Which of the following is an example of clinical data?

A) lab results
B) advance directive
C) financial data
D) consents for treatment
E) all of the above

Question 32

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

A) unidirectional data flow
B) bidirectional data flow
C) multidirectional data flow
D) data flow

Question 33

AHIMA record retention guidelines suggests a 5-year retention period for diagnostic images.

Question 34

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?

A) emergency room register
B) admission register
C) death register
D) all of the above

Question 35

A facility's record retention policy is best defined as which of the following?

A) The time period in which a person can bring a legal action for an injury or breach of contract.
B) General principles determining the length of time health data and the medical records in which that data is housed must be maintained by the health care provider.
C) A document that details what data will be retained, the retention period, and the manner in which the data will be stored.

Question 36

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

A) Statistical
B) Data
C) Numerical

Question 37

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.

Question 38

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?

A) The health care record belongs to the facility, and it cannot be mandated to produce the records.
B) Declining the request may violate the HIPAA Privacy Rule.
C) Paper-based charts must be reproduced for the patient, but electronic data is exempt from this ruling.

Question 39

There are only two components of records management data storage and retention.

Question 40

The problem-oriented health record was developed and popularized by

A) Lawrence Reed.
B) Lawrence Green.
C) Lawrence Weed.
D) none of the above.

Question 41

Match the terms with the best description.
refers to the method of identifying the health care provider who made an entry in the record

A)authorship
B)authentication
C)timeliness
D)completeness
E)source-oriented health record
F)problem-oriented health record
G)integrated health record

Question 42

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

A) Timeliness
B) Authentication
C) Authorship
D) Completeness

Question 43

The data collected and maintained by health care providers and organizations concerning their patients generally fall into one of two categories: administrative data or

A) data quality.
B) clinical quality.
C) clinical data.

Question 44

What type of health records have separate sections/areas for lab, physical therapy, and provider progress notes?

A) Source-oriented
B) Problem-oriented
C) Integrated

Question 45

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

Question 46

____________________ ____________________ focuses on determining the purpose, use, and users of the form and these determinations dictate the data elements to be contained in the form.

Question 47

___________ serves as a pointer, indicator, or guide to facilitate reference.

A) Registry
B) Index
C) Primary data
D) Secondary data

Question 48

Secondary databases include those centered within a particular health care facility-all EXCEPT the following:

A) Disease
B) Operative
C) Physician Indices
D) Medical Device Registry

Question 49

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

A)quantitative analysis
B)qualitative analysis
C)neither type of analysis applies

Question 50

Match the terms with the best description.
chart data follows a strict chronological order for organization

A)authorship
B)authentication
C)timeliness
D)completeness
E)source-oriented health record
F)problem-oriented health record
G)integrated health record

Question 51

Match the terms with the best description.
refers to the act of process of ensuring the entry in the record for both accuracy and authorship

A)authorship
B)authentication
C)timeliness
D)completeness
E)source-oriented health record
F)problem-oriented health record
G)integrated health record

Question 52

The process of collecting, tabulating, aggregating, and summarizing selected data elements.

A) Case finding
B) Case definition
C) MPI
D) Abstracting

Question 53

Governmental and accrediting entities utilize the data supplied to them by health care providers and organizations to assess compliance with

A) laws.
B) regulations.
C) accrediting standards.
D) all of the above.

Question 54

Match the terms with the best description.
progress notes are organized by the SOAP approach

A)authorship
B)authentication
C)timeliness
D)completeness
E)source-oriented health record
F)problem-oriented health record
G)integrated health record

Question 55

You have been asked to design a new form for a paper-based system. The two concepts that you should keep in mind as you develop the form in order to ensure both the flexibility and ease of use of the form are ____________________ and ____________________.

Question 56

____________________ ____________________ focuses on the management of the forms already designed, including how those forms will be amended or changed over time.

Question 57

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

A) Source-oriented
B) Problem-oriented
C) Integrated

Question 58

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

A) Quantitative
B) Qualitative
C) Data Quality

Question 59

Match the terms with the best description.
refers to entry of data in the health record at a suitable time period

A)authorship
B)authentication
C)timeliness
D)completeness
E)source-oriented health record
F)problem-oriented health record
G)integrated health record

Question 60

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

A)authorship
B)authentication
C)timeliness
D)completeness
E)source-oriented health record
F)problem-oriented health record
G)integrated health record

Question 61

Match the characteristic of data quality with its definition.
required data items are all collected

A)accuracy
B)accessibility
C)comprehensiveness
D)consistency
E)currency
F)definition
G)granularity
H)precision
I)relevancy
J)timeliness

Question 62

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

A)quantitative analysis
B)qualitative analysis
C)neither type of analysis applies

Question 63

Match the characteristic of data quality with its definition.
each data element is defined to the necessary level of detail

A)accuracy
B)accessibility
C)comprehensiveness
D)consistency
E)currency
F)definition
G)granularity
H)precision
I)relevancy
J)timeliness

Question 64

Match the type of analysis to the examples given.
vital signs are erroneously entered into the wrong health record

A)quantitative analysis
B)qualitative analysis
C)neither type of analysis applies

Question 65

Match the type of analysis to the examples given.
the quality of the medical care is thought to be substandard

A)quantitative analysis
B)qualitative analysis
C)neither type of analysis applies

Question 66

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

A)accuracy
B)accessibility
C)comprehensiveness
D)consistency
E)currency
F)definition
G)granularity
H)precision
I)relevancy
J)timeliness

Question 67

Match the characteristic of data quality with its definition.
data are collected easily and legally

A)accuracy
B)accessibility
C)comprehensiveness
D)consistency
E)currency
F)definition
G)granularity
H)precision
I)relevancy
J)timeliness

Question 68

Match the characteristic of data quality with its definition.
data is up-to-date at time of collection

A)accuracy
B)accessibility
C)comprehensiveness
D)consistency
E)currency
F)definition
G)granularity
H)precision
I)relevancy
J)timeliness

Question 69

Match the characteristic of data quality with its definition.
data values do not vary across applications

A)accuracy
B)accessibility
C)comprehensiveness
D)consistency
E)currency
F)definition
G)granularity
H)precision
I)relevancy
J)timeliness

Question 70

Match the characteristic of data quality with its definition.
each data element has a clear meaning

A)accuracy
B)accessibility
C)comprehensiveness
D)consistency
E)currency
F)definition
G)granularity
H)precision
I)relevancy
J)timeliness

Question 71

What does SOAP stand for? Give a brief example or description.

Question 72

What are the main three groups that share responsibility for the health care organization's compliance with the requirements for collecting and maintaining clinical data. Briefly describe the responsibility of each group.

Question 73

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

Question 74

Match the type of analysis to the examples given.
determining if sufficient documentation exists in the record to support billing a third-party insurer for the diagnoses reached or the procedures performed

A)quantitative analysis
B)qualitative analysis
C)neither type of analysis applies

Question 75

Match the characteristic of data quality with its definition.
each data element correlates in meaning to the collection purpose

A)accuracy
B)accessibility
C)comprehensiveness
D)consistency
E)currency
F)definition
G)granularity
H)precision
I)relevancy
J)timeliness

Question 76

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?

Question 77

Match the type of analysis to the examples given.
a chart review is done to determine that the requirements of statutory provisions, administrative regulations, accrediting standards, professional guidelines, and institutional standards are met

A)quantitative analysis
B)qualitative analysis
C)neither type of analysis applies

Question 78

Match the characteristic of data quality with its definition.
values are correct and valid

A)accuracy
B)accessibility
C)comprehensiveness
D)consistency
E)currency
F)definition
G)granularity
H)precision
I)relevancy
J)timeliness

Question 79

It is your responsibility to establish processes for collecting and maintaining clinical data at a facility. What criteria would you consider to accomplish this task?

Question 80

Match the characteristic of data quality with its definition.
data values fall within acceptable ranges

A)accuracy
B)accessibility
C)comprehensiveness
D)consistency
E)currency
F)definition
G)granularity
H)precision
I)relevancy
J)timeliness