Deck 4: Data Quality and Management

Question 1

The process of documentation into an electronic record is called:

A) data entry.
B) postdischarge processing.
C) abstracting.
D) collection.

Answer 1

data entry.

Question 2

Access to a patient's health record is tracked using a(n)

A) audit trail
B) exception file
C) concurrent analysis
D) error report

Answer 2

audit trail

Question 3

A pharmacy collects information on new customers, including whether the customer owns or rents a home. The pharmacy does not require this data and never uses it to make decisions. Based on data quality characteristics, this data:

A) should be collected, because it is accurate
B) should not be collected because it is not relevant
C) should be collected, because it contributes to completeness
D) should not be collected because it is not consistent

Answer 3

should not be collected because it is not relevant

Question 4

Which reflects data timeliness?

A) Laboratory results are waiting to be scanned into the patient's record at nursing station 3.
B) Laboratory results were entered into the patient's electronic health record a few hours after they arrived.
C) Dr. Johnson had to call the medical clinic out of state to get the patient's previous laboratory results.
D) A laboratory report was just scanned into the record of a patient who was discharged 42 days ago.

Question 5

The medical assistant logs into the health record, but she cannot update the patient's tobacco use because she is not assigned the proper user role. Which data quality characteristic is lacking?

A) accessibility
B) precision
C) granularity
D) relevancy

Question 6

The medical assistant wrote that the patient had "pain in the arm," which left the provider wondering whether it was the left arm or right arm, as well as where on the arm the patient felt pain. The problem with the medical assistant's note is that it lacks

A) accessibility
B) precision
C) granularity
D) relevancy

Question 7

A certain medication dosage is determined by the patient's weight, but it has been two months since the last time the patient was weighed at the office. The provider will not use the old data because it is not

A) accessible
B) relevant
C) granular
D) current

Question 8

The HIM professional offers a data dictionary to all the collectors and users of the database, so that everyone knows what a given field represents and how to collect and record those data. The data quality characteristic being illustrated is data

A) relevancy
B) definition
C) granularity
D) currency

Question 9

Which is a detective control?

A) A nurse alerts a provider that a patient is allergic to an ordered medication.
B) The nursing supervisor reviews a record to ensure that medication administration notes were properly entered.
C) The health information management (HIM) department sends a physician a list of the incomplete records.
D) A coder reviews a record in order to assign a clinical code.

Question 10

When recording the patient's use of oxygen, the nurse can only select from a list of four choices. Which type of control is this?

A) detective
B) corrective
C) ancillary
D) preventive

Question 11

While the patients are sleeping, nurses on the night shift review the charts of current inpatients to make sure certain elements are properly recorded. This is a ____________ internal control.

A) preventive
B) retrospective
C) corrective
D) detective

Question 12

Which is a preventive control?

A) The CPOE alerts the provider about a contraindication for a medication she is ordering.
B) The nursing supervisor reviews charts to ensure that progress notes are being recorded.
C) The deficiency system sends email reminders to physicians about incomplete records.
D) A coder uses an encoder to assign a procedure code.

Question 13

Which statement about making corrections in the health record is true?

A) the original note should be legible
B) the original note should be completed obscured
C) the Joint Commission should be notified
D) new entries should be typed or written in red

Question 14

Which control cannot be used retrospectively?

A) corrective
B) detective
C) preventive
D) root cause analysis (RCA)

Question 15

A list of deficient or other problem data, usually generated by a computer, is called an error report or __________ report.

A) deficiency
B) batch control
C) exception
D) root cause analysis (RCA)

Question 16

A patient with a seafood allergy had a reaction to the contrast dye used during her x-ray hysterosalpingography (HSG). The facility began a ______________ to determine how the error happened.

A) detective control
B) nonrepudiation analysis
C) exception report
D) root cause analysis (RCA)

Question 17

Which is a function of information governance?

A) monitoring data quality and integrity within the EHR
B) ensuring accurate data collection by patient access staff
C) regular meetings of the forms committee
D) making policy for how data will be used in a health information exchange (HIE)

Question 18

Data governance is concerned with:

A) policies for collecting data at the point of care.
B) release of information policy.
C) monitoring staff credentials.
D) how the facility's systems interface with pharmacies

Question 19

The patient account number and medical record number

A) are listed on the discharge register.
B) change with each visit or encounter.
C) are two names for the same data element.
D) are assigned by the medical coder.

Question 20

The HIM department can verify which patient records are available for processing by referring to the

A) admission register
B) audit trail
C) discharge register
D) exception report

Question 21

Housekeeping is notified to clean the room

A) once a new patient is ready to be admitted.
B) after a patient is discharged.
C) after the discharge register is created.
D) after the midnight census.

Question 22

The set of procedures by which paper portions of the record are ordered for scanning or further processing is

A) assembly
B) quantitative analysis
C) point-of-care documentation
D) abstracting

Question 23

Using _____________, many paper documents are digitized at once, after which software sorts the documents into the correct record by bar code.

A) batch scanning
B) abstracting
C) encryption
D) indexing

Question 24

What is another term that refers to the period postdischarge?

A) concurrent
B) nonrepudiation
C) quantitative
D) retrospective

Question 25

Documents entered into the health record as images must be ___________ for identification and future retrieval.

A) scanned
B) indexed
C) rekeyed
D) abstracted

Question 26

Which patient would be found on a discharge register for May 1st?

A) A patient who was admitted to the hospital on May 1st and discharged on May 2nd
B) A patient who was admitted to the hospital on May 1st and died on May 2nd
C) A patient who was admitted to the hospital on April 30 and discharged on May 1st
D) A patient who was dead on arrival on May 1st

Question 27

Quantitative analysis is usually performed by a(n)

A) case manager
B) site surveyor
C) HIM professional
D) medical assistant

Question 28

Each element of the record must be properly dated, timed, and ______________ in accordance with the rules and regulations of state or accrediting agencies that apply to the facility, with the authors clearly identified.

A) authenticated
B) completed
C) transcribed
D) corrected

Question 29

Which is NOT identified during quantitative analysis?

A) missing signature on a physician progress note.
B) discharge report has not been dictated.
C) requested cardiology consultation was not performed.
D) history and physical (H&P) was dictated and transcribed on the third day of the admission.

Question 30

The assignment of physicians to cases-attending, consultants, and surgeons-is called _____________.

A) authentication
B) assembly
C) attribution
D) completion

Question 31

The Joint Commission (TJC) considers incomplete acute care records delinquent

A) 15 days after discharge.
B) 5 days after discharge.
C) 30 days after discharge.
D) 150 days after discharge.

Question 32

When a patient is being admitted for a health-related issue, the physician must state the patient's ___________.

A) symptoms
B) procedures
C) chief complaint
D) diagnosis

Question 33

Community Hospital, an acute care facility, is preparing for TJC survey. The Chief Operating Officer is reviewing the following data from the HIM department:
Using the information above, at the end of April, is Community Hospital in compliance with TJC rules regarding the number of delinquent records permitted?

A) Yes.
B) No.
C) Not enough information is given to answer the question.
D) The question is moot, since TJC does not permit delinquent records.

Question 34

__________________ specialists assist physicians in achieving the best possible documentation of their medical decision-making process.

A) Clinical documentation improvement (CDI)
B) The Joint Commission (TJC)
C) Patient Navigation
D) Revenue Cycle

Question 35

Why is concurrent coding beneficial?

A) Allows the facility to bill the insurance company prior to discharge.
B) Ensures that all clinical personnel are aware of the admitting diagnosis.
C) Gives the physician the correct principal diagnosis.
D) Helps estimate the length of the patient's hospital stay.

Question 36

Which describes computer-assisted coding (CAC)?

A) The software analyzes documents and assigns codes
B) The software reads codes and creates health records
C) The software analyzes symptoms and assigns codes
D) The coder uses software to look up codes

Question 37

At registration, the patient access clerk searches the ____________ history files to determine whether the patient has been treated at the facility on a previous occasion.

A) abstract database
B) batch control form
C) discharge register
D) master patient index (MPI)

Question 38

Why do HIM professionals look for duplicate medical record numbers of the same patient and merge them?

A) to facilitate continuity of care in a single record
B) to save space in the file room, on the server, or in the cloud
C) to reuse old medical record numbers
D) to prevent staff from creating new patients in the master patient index

Question 39

A summary of the patient's record is created during the ___________ step of postdischarge processing.

A) abstracting
B) indexing
C) coding
D) record completion

Question 40

Patient records are sometimes abstracted for __________, collections of data specific to a disease, diagnosis, or procedure.

A) data sets
B) registries
C) indices
D) vital statistics

Question 41

The processing status of records is listed on the

A) deficiency sheet
B) batch control form
C) exception report
D) workflow

Question 42

Which is a hallmark of efficient paper record processing?

A) records are moved as little as possible
B) steps are completed at the same time (concurrently) whenever possible
C) the record is coded before it is scanned
D) photocopies of the record are kept in the master file

Question 43

When speech recognition software is used for transcription:

A) the author can view the transcription concurrently
B) no digital signature is necessary
C) properly formatted reports are not an issue
D) physicians are discouraged from typing or writing by hand

Question 44

In the electronic environment, workflow describes how the electronic record moves from one __________ to another.

A) queue
B) batch
C) file
D) database

Question 45

The release of information function is part of the ___________ component of record retention.

A) storage
B) security
C) access
D) governance

Question 46

When an individual enters a user identification and password into the EHR system, the content shown is

A) limited by security clearance
B) limited by facility privileges
C) limited by user role
D) unlimited

Question 47

Under the Health Insurance Portability and Accountability Act (HIPAA), which is a business associate?

A) provider
B) transcription service
C) health insurer
D) patient

Question 48

Sam, the HIM Director at Providence Hospital, suspects that some of his employees have been viewing patient records that they do not need to access for their work. What should Sam do?

A) Change all employee passwords.
B) Review an audit trail.
C) Contact the Office for Civil Rights (OCR).
D) Change their user roles in the system.

Question 49

Which part of the Health Insurance Portability and Accountability Act (HIPAA) requires covered entities to perform a risk assessment and establish administrative, technical, and physical safeguards?

A) The Privacy Rule
B) The Security Rule
C) The Protected Health Information (PHI) Rule
D) The Integrity Rule

Question 50

Which statement about protected health information (PHI) is true?

A) it may only be seen by the patient
B) health care professionals may view it at any time
C) it may only be disclosed when the patient consents, with no exceptions
D) health care professionals may only access it on a need-to-know basis

Question 51

Which is an example of protected health information (PHI)?

A) A list of patient names on a sign-in sheet at a clinic
B) A chart showing the number of discharges for the year
C) A printout of patients who have had Cesarean sections.
D) A pamphlet on Type 2 diabetes.

Question 52

The medical assistant is curious why her brother-in-law, who is the patient of a provider at a different branch of the health care organization, has so many doctor's appointments. Is it legal for her to look at his health record? Why or why not?

A) No, because she has no clinical or administrative reason to do so.
B) No, because MAs cannot access health records.
C) Yes, because the MA is a family member.
D) Yes, because the MA is an employee of the same health care organization.

Question 53

Melissa had back surgery six months ago, and is still having some pain. Which situation would require her to sign a release of information (ROI) form?

A) to authorize the payer to reimburse the provider
B) to consent to another surgical procedure
C) to obtain a copy of her operative report
D) to allow the surgeon to view her operative report

Question 54

Overseas hackers gained access to the hospital's EHR and threatened to make health records public unless they received a large sum of money. When the crisis is over and the hospital regains control, what is the problem with the health records?

A) their integrity is in question
B) they may not be encrypted
C) they are no longer interoperable
D) they may have viruses or malware

Question 55

Which scenario is a breach?

A) Nurses discussing Mrs. Logan's patient care during morning report
B) An HIM employee discussing his migraines with his neighbor
C) A hospital employee reviewing the record of a celebrity currently admitted to the facility
D) An administrator who left sales figures on the train

Question 56

The new nursing supervisor is discussing her plans for the unit with you. She wants to hang a board on the wall of the nursing unit listing each patient's name, room number, working diagnosis, and medication schedule. You advise her that:

A) this is a violation of physician privileges
B) this is a violation of record integrity
C) the display of patient-identifiable information in a public place is a violation of the Security Rule
D) the display of patient-identifiable information in a public place is a violation of the Privacy Rule

Question 57

Which is a technical safeguard?

A) automatic logoffs
B) sharing of passwords among health care providers
C) a locked filing cabinet
D) the appointment of a security officer

Question 58

Which statement is true about the use of the Internet in the health care setting?

A) the Health Insurance Portability and Accountability Act (HIPAA) makes it illegal for anyone in the facility to use the Internet.
B) Per Freedom of Information Act rules, employers may not forbid employees from accessing the Internet.
C) Employees may only use the Intranet or the facility-wide Wifi.
D) The facility does not need policies describing appropriate use of the Internet.

Question 59

Which statement is true about the use of the patient's health record in a legal dispute?

A) the health record cannot be used in a court of law
B) the health record is in the public domain and may be accessed freely
C) the health record may be used to defend the provider's actions
D) the health record is only used for legal matters when the patient is injured

Question 60

Which is an external use of health information?

A) develop community awareness of health care issues
B) demonstrate compliance with regulations and accreditation
C) support reimbursement
D) develop facility resource utilization statistics

Question 61

Which patient has low health literacy?

A) the patient who avoids going to the doctor
B) the patient who does not understand discharge instructions
C) the patient who cannot afford to pay
D) the patient who is addicted to painkillers

Question 62

Which patient is health literate?

A) the patient who understands medical terms
B) the patient who understands the risks and benefits of a treatment
C) the patient who correctly diagnoses himself using information from the Internet
D) the patient who reads American Sign Language (ASL)

Question 63

Which is an example of health information being used by facility administration?

A) providing disease statistics to a state agency
B) using outcomes data to develop a new treatment
C) counting diagnoses to evaluate the need for new services
D) faculty teaching students about a disease process

Question 64

A facility may use health information for _______________, the promotion of its services, to patients who have opted in.

A) managed care
B) marketing
C) research
D) administration

Question 65

Healthy People is a _______________ program that compiles data on indicators of health.

A) local
B) regional
C) state
D) national

Question 66

During assembly, paper components are typically ___________ into the computer system through the use of an electronic document management system (EDMS).

Question 67

The term _______________ means that a person can be identified by their signature.

Question 68

Before creating a new patient health record, registrars always check the _______________ patient index to see if an individual has been a patient at the facility before.

Question 69

The process of ___________ identifies or names a part of the record so that it can be located in the computer-based health record.

Question 70

The __________ rate refers to how often disease occurs within a population.

Question 71

In health care, documentation from previous patient care allows physicians and scientists to __________, gaining knowledge to improve, develop, or change patient care and technology.