Term
| You are developing a complete data dictionary for your facility. What resource will be most helpful in providing standard definitions for data commonly collected in ACUTE CARE HOSPITALS? |
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Definition
| Uniform Hospital Discharge Data Set (UHDS) |
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Term
| What document is generated by EMTs to provide clinical information such as vital signs, level of consciousness, appearance of the patient, and so on when a patient is transported via ambulance to the emergency department. Although the ER will begin a record on the patient, noting time and means of arrival, what report will be used to review patient's condition upon arrival? |
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Definition
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Term
| Using the SOAP style of documenting progress notes, what would be a subjective statement? |
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Definition
| Patient states low back pain is as severe as it was on admission. Subjective is from the view point of the patient. |
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Term
| In what record numbering system is the patient assigned a health record number on the first visit that is kept for all subsequent visits? |
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Definition
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Term
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Definition
| Data that is free of errors. |
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Term
| What is the name of the economic package President Obama signed into law in 2009, providing reimbursement incentives to provider and hospital that are "meaningful users" of certified EHR technology? |
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Definition
| ARRA- American Recovery and Reinvestment Act of 2009. |
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Term
| Do you have the right to obtain the original health record from the facility that created it? |
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Definition
| No. The hospital owns the record. Unless subpoenaed by a court of law, the facility must keep the original. They will however, provide you a copy. The patient owns the information int he record, but not the physical record. |
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Term
St. Mary's is using a numbering system where as six patients admitted to the hospital on Tuesday, 9/18 had the following patient numbers, in this order:
9010, 2053, 9011, 9012, 3155, 0381
Which numbering system is being used at St. Mary's. |
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Definition
| Unit. The numbering system represents how a unit numbering system admission roster would appear. The first patient that day has never been there before, so he/she is assigned the next available number 9010 (day before, last patient assigned a number was given 9009). Then, the next person admitted has been there before, so he/she keeps her old number 2053. The third patient is new, so he/she gets the number after 9010, the fourth patient is new, so he/she receives 9012, the back to another patient who has already received a number in the past, etc. |
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Term
| You have been appointed as chair of the Health Record Committee at a new hospital. Your committee has been asked to recommend time-limited documentation standards for inclusion in the Medical Staff By-laws, Rules, and Regulations. The committee documentation standards must meet the standards of both The Joint Commission and the Medicare Conditions of Participation. The history and physical is discussed first. You advise them that the time period for completion of this report should be set at: |
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Definition
| 24 hours after admission or prior to surgery. |
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Term
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Definition
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Term
| The number that has been proposed for use as a unique patient identification number but controversial because of confidentiality and privacy concerns is the |
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Definition
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Term
| The primary purpose of a minimum data set in healthcare is to |
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Definition
| recommend common data elements to be collected in health records. Definition of data sets/recommended data elements with uniform definitions. |
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Term
A notation for a diabetic patient in a physician progress note (SOAP) reads:
Patient states she occasionally gets hungry, has no insulin reactions, an is following her diabetic diet.
In which part of the POR progress note would this notation be written? |
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Definition
| Subjective. "patient states..." is always subjective. |
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Term
| In an acute care hospital, a complete H&P might not have to be dictated for a new admission. This could occur when: |
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Definition
| The patient is readmitted with a similar problem and a legible copy of a recent H&P (less than 30 days) is available. This is referred to as interval H&P. |
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Term
| Individuals who receive acute care services in a hospital are considered what? |
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Definition
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Term
| Which numerical filing system results in an even distribution of records and ensures activity throughout the filing area? |
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Definition
| terminal-digit filing system |
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Term
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Definition
| Living wills, durable power of attorney for healthcare, dnr, dni |
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Term
| A health record with deficiencies that is not complete within the time frame specified in the medical staff rules and regulations is called a/an: |
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Definition
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Term
| Hospitals can be classified by which of the following? |
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Definition
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Term
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Definition
| a voluntary system of institutional review in which an independent body periodically evaluates the quality of the services provided by healthcare organizations against a written criteria. The Joint Commission is the largest. |
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Term
| Secondary Purpose of the Health Record |
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Definition
| example: support for research... A secondary use of the record would be research, as the information used is not "patient identifiable". but is de-identified for aggregate purposes. Secondary purposes do not involve specific encounters between patient and a healthcare provider. |
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Term
Element of H&P:
"I had a headache on Monday. My headache has persisted, plus on Tuesday my cheeks started hurting. Today I have a temperature" |
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Definition
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Term
Element of H&P:
"I have had a sore throat for 5 days" |
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Definition
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Term
Element of H&P:
I am a smoker and a drinker. My dad died of lung cancer last year." |
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Definition
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Term
Element of H&P:
General: Usual weight, fever, weakness, fatigue?
Skin: rashes, eruptions, dryness, cyanosis, jaundice?
Head: Headache
Eyes: glasses or contact lenses, last eye examination, pain, redness, blurring?
Ears: hearing, discharge, dizziness, pain?
Nose: head colds, epitaxis (nose bleeds), postnasal drip, sinus pain?
etc |
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Definition
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Term
| What is the difference between data and information? |
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Definition
| Data is a basic fact; information represents meaning. |
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Term
| What is the general name for Medicare standards impacting healthcare organizations? |
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Definition
| Conditions of Participation. |
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Term
| Who is primarily responsible for documenting information in the patient record? |
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Definition
| direct patent care documentation is done by physicians and other clinical health care providers. Medical by-laws will describe, in detail, who may or may not document in the health record. |
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Term
| A general consent to treatment includes consent for TPO. What does this stand for? |
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Definition
| treatment, payment, and healthcare options. |
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Term
| The inpatient data set that has been incorporated into federal law and is required for Medicare reporting is the |
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Definition
| Uniform Hospital Discharge Data Set UHDDS. This was the first data set created to develop standardization in hospital data collection. |
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Term
| A core data set developed by ASTM to communicate a patient's past and current health information as the patient's transitions from one care setting to another is: |
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Definition
| continuity of care record. a CCR is a core data set of relevant administrative, demographic, and clinical information about a patient's health status and treatment. it was created to help communication of patient information from one provider to another. |
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Term
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Definition
| Attending physicians is responsible for docmentation: This is a concise account of the patient's illness, course of treatment, response to treatment, and condition at the time the patient is discharged from the hospital. |
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Term
| The admissions form in an acute care hospital is usually referred to as a(n): |
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Definition
| Face Sheet. Must be completed and signed by the attending physician within 30 days of discharge. |
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Term
| Mr. Jones was admitted to the hospital on 1/3/7 and given the MRN# 22-55-69. He was readmitted to the hospital on 3/6/7 and given the MRN# 26-55-93. In a serial-unit numbering system, how would his health record be filed? |
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Definition
| Mr. Jone's record #22-55-69 would be moved forward and filed with #26-55-93. A serial-unit numbering system is a combination of serial numbering (consecutive numbers for each encounter), filed all together (unit) with the most current visit/encounter at that facility. |
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Term
| The admitting data of Mr. Smith's record indicates that her DOB was 3/21/48. On the discharge summary, Mrs. Smith's DOB was recorded as 7/21/48. Which of the ten specific data quality characteristics is missing from Mrs. Smith's health record? |
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Definition
| Data consistency. Consistence means no matter where or in what form, the data is the same. |
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Term
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Definition
| Review while patient is still in the hospital. |
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Term
| St Mary's is using both manual and electronic processes for the health records. What term describes a record that, at this time, is using both paper and electronic formats? |
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Definition
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Term
| What is the defining characteristic of an integrated health record format? |
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Definition
| Integrated health record components are arranged in strict chronological order (or reverse chronological order). Integrated format of a medical record files documents in "time" order, combining all document sources as they occur. This order is either in chronological or reverse chronological order. |
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Term
| Who determines who can receive and transcribe verbal orders? |
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Definition
| Medical staff bylaws. State law and medical staff rules specify which practitioners are allowed to accept and execute verbal and telephone orders. How the orders are to be signed as well as the time period allowed for authentication also may be be specified. |
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Term
| Mary has documented the fact that her patient has an advance directive. She has asked the patient if he wants to include this document in the health record. He tells her no, but a family member has a copy at home, just in case one is needed. In this instance, is it legal for Mary to not include the advance directive in the health record? |
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Definition
| Yes, because the PSDA states only that the patient has a right to have in included in the health record. The patient may choose to not include one. The PSDA is federal legislation that requires healthcare facilities to provide written information on the patient's right to issue advance directives and to accept or refuse medical treatment, based on their wishes. |
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Term
| A HIM department plans to purchase some new open-shelf filing units. Each unit has 7 shelves. Each shelf measures 36 linear filing inches. Assume each record requires one inch of linear space. It is estimated that an additional 1000 inches should be planned for to allow for expansion. How many new file shelving units should be purchased? |
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Definition
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Term
| When must a surgeon document the events of a surgical procedure? |
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Definition
| Immediately. This may be a formal report, if there is time, or a detailed operative note in the progress notes until a formal report can be filed. However, waiting for 24, 36, or 48 hours in unacceptable. |
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Term
| Quantitative Analysis Review |
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Definition
| looks for patient identification on each form, form presence, signatures, correct order. Analyzing a patient's drug profile with the MAR and diagnosis is part of the qualitative analysis. |
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Term
| In terminal-digit filing what number would come immediately before and after 99-12-36? |
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Definition
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Term
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Definition
| The right of individuals to control access to their personal health information. |
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Term
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Definition
| The expectation that the personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose. |
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Term
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Definition
| The protection of healthcare facilities from vandalism and theft. |
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Term
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Definition
| The process of disclosing health record documentation originally created by a different provider. |
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Term
| How do accreditation organizations use the health record? |
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Definition
| to determine whether standards of care are being met. |
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Term
| Which of the following encourages patients to take an active role in collecting and storing their health information? |
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Definition
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Term
| In healthcare, data sets serve two purposes. The first purpose is to identify data elements to be collected about each patient. The second is to: |
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Definition
| provide uniform data definitions. We must all collect data in exactly the same way. That data must be clearly define so that data is standardized. |
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Term
| What would not be a reason for using an application service provider model? |
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Definition
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Term
| What kind of technology: Microsoft Word |
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Definition
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Term
| What kind of technology: Anti-Viruses R Us |
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Definition
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Term
| What kind of technology: MS DOS or Windows |
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Definition
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Term
| What kind of technology: Artificial Intelligence |
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Definition
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Term
| This section of the HIPAA Security Rule involves establishing safeguards that protect equipment, media, or facilities. In addition, computer monitor positioning and locks on computers and terminals should be addressed. What category of the security standards does this fall under? |
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Definition
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Term
| In a relational database table. What is an alternative name for each row? |
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Definition
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Term
A PACS is a computerized system for reporting results of laboratory results.
true/false |
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Definition
| False. Picture archiving and communication system is a medical imaging technology which provides economical storage of, and conventient access to, images from multiple modalities (source machine types). This eliminates the need to manually file, retrieve, or transport film jackets. |
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Term
| President Bush assigned which of the following governmental agencies as the leader in adoption of the electronic health record? |
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Definition
| Office of the Nation Coordinator for HIT. The ONC is a department of the USDHHS, established by executive order to advance the development, adoption, and implementation of HIT standards. |
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Term
| St. Have Mercy Hospital needs to prepare for the next hurricane. What should the facility have in place, in case of disaster? |
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Definition
| BCP. A business continuity plan is a program that incorporates policies and procedures for continuing business operations during a computer shutdown; sometimes this is referred to as a contingency and disaster plan. |
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Term
| You are walking around your facility conducting a risk assessment to identify privacy and security issues. You walk onto the 6W nursing and unit and are able to watch the nurse entering confidential patient information. How can you best improve the privacy of the patients? |
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Definition
| turn the computer screen so the public cannot see it. |
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Term
| Don Johnson, a lab employee at St. Have Mercy Hospital, lost his ID badge yesterday. He used another lab employee's badge today because he needed to access the computer system to complete his work. His plan was to report his badge missing after work, but for today, he didn't think it would really matter. What controls should have been in place to minimize the chance of this happening? |
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Definition
| better workforce security awareness training. |
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Term
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Definition
| made following a step by step process such as an encoder. Structured data is also known as discrete data, consisting of raw facts or figures that can be processed by the computer. (lab values,medication dosages, date of a vaccine, etc.) |
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Term
| ___________ is the term used to describe voice and data communications. |
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Definition
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Term
| As HIM director, you are involved in a project to assist the systems analyst in creating a central repository of all data elements utilized in the MPI database. An example of this documentation includes Length: 1 character, Type: alphanumeric, Value: M=Male and F=Female. This resource is known as what? |
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Definition
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Term
| What would not be a reason for using an application service provider model? |
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Definition
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Term
| What kind of technology: Microsoft Word |
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Definition
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Term
| What kind of technology: Anti-Viruses R Us |
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Definition
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Term
| What kind of technology: MS DOS or Windows |
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Definition
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Term
| What kind of technology: Artificial Intelligence |
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Definition
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