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242 Midterm Review
| Question | Answer |
|---|---|
| When dealing with a healthcare organization, the data may be | structure, semi-structured, unstructured |
| A valuable tool for clinical research that relates to the EHR includes the use of the secured __________ to reach potential research and study subjects as part of clinical trials. | patient portal |
| The effective ongoing management of data assets is critical to maintaining the __________ of data in organizations: | integrity |
| The concept of data oversight is most effectively administered through a strategic _________ program. | data governance |
| What are the four Vs of big data? | volume, velocity, veracity, value |
| Unstructured data are stored in non-discrete formats. Examples include: | text reports and summaries |
| When the physician enters orders in the EHR, the software automatically confirms the authentication to ensure that the individual who entered the data is authorized to do so, this is an example of a computer being used to ensure data | validity |
| As an HIM professional working on IG initiatives, it is important to find out how the data in the organization is collected, stored and analyzed because: | It needs to be able to be trustworthy and have the highest integrity and quality. |
| AHRQ’s quality indicators (QI) are _________________________ | measures of healthcare quality that make use of readily available hospital inpatient administrative data |
| CDI is an accurate description of a patient’s clinical status into coded data, which is then translated into: | a quality report |
| The IG levels of maturity are a(n) ____________ platform divided into five different levels. | Scalable |
| Data becomes __________________ when something is done to that data to make it meaningful | Information |
| The process of identifying common elements in two or more data sets is known as ________. | data mapping |
| When applying the principle of data relevancy, which of the following data would apply? | eye color |
| An audit of a hospital's electronic health system shows that diagnostic codes are not being reported at the correct level of detail. This indicates a problem with data: | granularity |
| True or false? The purpose of CDI is to increase reimbursement. | false |
| The pre-existing condition that affects the treatment received and or prolongs the length of stay | comorbidity |
| The most important outcome of a CDI program is: | Documentation that describes the patient's condition and treatment as accurately as possible. |
| A physician is reviewing the lab results of a patient in his office. The EHR screen displays one set of results in red with a flashing asterisk and also shows that this result is three times higher than the expected value. This a(n) ________. | alert |
| Queries performed _______ are developed during the patient's stay at the facility or organization. | concurrently |
| Reflects the expected intensity of resources needed to care for the patient? | severity of illness (SOI) |
| When healthcare facilities use a hybrid health record, what is the best strategy for discharge analysis? | The healthcare facility should identify the minimum discharge data elements both in the EHR and the hybrid records to develop a process to incorporate analysis of both types of records. |
| The healthcare facility should identify the minimum discharge data elements both in the EHR and the hybrid records to develop a process to incorporate analysis of both types of records. | The amendment must have separate authentication, data and time. |
| Which of the following technologies has been demonstrated to significantly reduce medication administrative errors? | Computer physician order entry (CPOE) |
| Which of the following is an example of unstructured data? | provider notes |
| Which of the following is the biggest challenge of using a regional health information exchange? | identifying the correct patient |
| Essential patient information, such as patient allergies, needs to be highlighted to each member of the healthcare team. Which of the following EHR feature best highlights this? | bright color alert on the EHR dashboard |
| Which of the following documents is a clinical document? | physical examination |
| Which of these organizations mandates accreditation standards for discharge summaries? | The Joint Commission |
| Which one of the following documents contains information about pertinent laboratory, radiology, therapy and consultations? | Discharge Summary |
| The primary purpose of healthcare documentation is ________. | To chronicle patients' health over time |
| What are used to sort data in a variety of ways to assist study of certain data elements? | Indexes |
| Who is responsible for the collection of vital statistics? | State |
| The physician monitored Stacey’s fluid input and output over several days to ensure she was hydrated. The use of the collected data is an example of: | primary data |
| Data elements included in the MPI should: | Accurately match patients being registered for care with their MPI records. |
| What is the general name for Medicare standards impacting healthcare organizations? | Conditions of Participation |
| Before a physician will be permitted to provide patient services in a specific facility, he or she must first go through which of the following processes? | Credentialing |
| Before a hospital is permitted to provide medical services in a particular state, the organization must first go through which of the following processes? | Licensure |
| What type of data are consents and authorizations? | administrative |
| The e-discovery amendments may be found in which of the following documents? | federal rules of civil procedure |
| Which of the following dictates the maximum period of time that may elapse between an event and any consequent legal action in a specific geopolitical area? | Statute of limitations |
| What does the abbreviation OCR stand for? | Office for Civil Rights |
| CLIA is focused to which service line? | Laboratory |
| Defining the legal record becomes __________ as organizations with EHRs. | Complex |
| The _________ is the driving force behind movement toward the universal adoption of EHR systems. | Health Insurance Portability and Accountability Act (HIPAA) |
| Copies of personal health records (PHRs) are considered part of the legal health record when: | Used by the organization to provide treatment |
| What Federal agency is charged with improving the safety and quality of America's healthcare system? | Agency for Healthcare Research and Quality |
| The push for hospital reform was initiated by _____________________. | American College of Surgeons |
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