question

Which of the following best describes the most important function of the health record?

answer

Storing patient care documentation

question

Who are the primary users of the health record?

answer

Clinical professionals who provide direct patient care.

question

Which of the following elements is not a component of most patient records?

answer

Financial information.

question

Healthcare information systems need to exchange information. This linkage between systems is referred to as:

answer

Connectivity.

question

Which of the following is NOT a characteristic of high-quality healthcare data?

answer

Data accountability

question

Which of the following represents and example of data granularity?

answer

A numerical measurement carried out to the appropriate decimal place.

question

What is the defining characteristic of an integrated health record format?

answer

Integrated health record components are arranged in strict chronological order.

question

Critique this statement: Electronic health record systems have the same access control requirements as paper based record systems.

answer

This is a true statement.

question

Critique this statement: Paper based record systems are not flexible enough to meet all of the needs of every health record user.

answer

This is a true statement.

question

Which of the following best describes data accuracy?

answer

Data are correct.

question

Which of the following best describes data completeness?

answer

Data include all required elements.

question

Which of the following best describes data accessibility?

answer

Data are easy to obtain.

question

Data definition refers to the:

answer

Meaning of data.

question

Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missing from the progress note?

answer

Data currency.

question

The admitting form of Mrs. Smith's health record indicated that her birth date was March 21, 1948. On the discharge summary, Mrs. Smith's birth date was recorded as July 1, 1948. Which quality element is missing from Mrs. Smith's health record?

answer

Data consistency.

question

I need an information system that will provide assistance to physicians in diagnosing and treating patients. The system that I need is:

answer

Clinical decision support.

question

I have been asked to list institutional users of the health record. Which one of the following would I include in my list?

answer

Blue Cross and Blue Shield of Arkansas.

question

In the context of the healthcare record, security can be defined as:

answer

The protection of the privacy of individuals and the confidentiality of health records.

question

What is one of the improvements found by using a computerized provider order entry (COPE) SYSTEM?

answer

Eliminate issues with illegible handwriting.

question

Arkansas's health information exchange is known as:

answer

SHARE

question

A nurse is responsible for which of the following types of acute care documentation?

answer

Medication record

question

When correcting erroneous information in a paper health record, which of the following is not appropriate?

answer

Use black pen to obliterate the entry.

question

Which accrediting organization has instituted unannounced surveys and requires submission of annual performance reviews?

answer

Joint Commission

question

Documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleaning would be found in which type of specialty record?

answer

Home health

question

Which of the following groups is the primary accreditation organization for facilities that treat individuals who have functional disabilities?

answer

Commission on Accreditation of Rehabilitation Facilities

question

Which type of health record is designed to measure clinical outcomes, collect data at the point of care, and provide medical alerts?

answer

Electronic record

question

Which of the following is an advantage of paper-based records?

answer

Standardized familiar format

question

\"The patient indicates that she is dizzy, nauseous, and feels her throat tightening.\" This entry would be recorded in which section of a SOAP note?

answer

Subjective

question

Which of the following organizations drafted more than 130 functional standards for electronic health records?

answer

Health Level Seven (HL7)

question

Which type of patient care record includes documentation of a family bereavement period?

answer

Hospice record

question

Documentation of genetic information, immunizations, hospitalizations, surgeries, medications, and personal, family, occupational and environmental histories are maintained over a lifetime in what type of record?

answer

Personal health record

question

In which setting may treatment records travel with the patient between treatment centers?

answer

Correctional facility care

question

An RAI/MDS and care plan are found in records of patients in:

answer

Long-term care

question

Which of the following is not an example of a long-term care setting?

answer

Community mental health centers

question

Which of the following represents the attending physician's assessment of the patient's current health status?

answer

Physical examination

question

Patient history questionnaires are most often used in:

answer

Ambulatory care

question

In a medical history, which of the following is a detailed chronological description of the development of the patient's illness?

answer

Present illness

question

Which of the following is an example of an advance directive?

answer

Living will

question

What is the function of physician's orders?

answer

Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care

question

Which of the following contains the physician's findings based on an examination of the patient?

answer

Physical exam

question

Which of the following represents documentation of the patient's current and past health status?

answer

Medical history

question

Which of the following is true of computer-based records?

answer

Can be accessed by multiple end users simultaneously

question

Documentation standards and guidelines are published by a variety of private and public organizations, including the:

answer

All of the above

question

Which type of specialized record includes care provided prior to arrival at a healthcare setting and times and means of arrival?

answer

Emergency care record

question

The number of ligatures, sutures, packs, drains, and sponges used and specimens removed would be found in the:

answer

Operative report

question

Which of the following is an example of clinical data?

answer

Admitting diagnosis

question

The attending physician is responsible for which of the following types of acute- care documentation?

answer

Discharge summary

question

Which of the following is not usually a component of acute care patient records?

answer

Problem list

question

The key data element for linking data about an individual who is seen in a variety of settings is the:

answer

Unique patient identifier

question

Information standarda that provide clear descriptors of data elements to br includes in computer-based patient record systems are called___standards:

answer

Structure and content

question

In designing an electronic health rexord, one of the best resources to use in helping to define the content of the record as well as to standarized data definitions is the E1384 standard promulgated by the:

answer

American Society for Testing and Measurment

question

Of the following resourses, the best reaource to use in dedining the structure of the EHR is the:

answer

HL7 Functional Model

question

The___mandated the development of standards for medical records.

answer

Health Indurance Portability and Accountability Act of 1996.

question

Messaging standards for electronic data interchange in healthcare have been developed by:

answer

HL7

question

AHIMA strongly opposes the use of which the following as a patient identifier in an electronic enviroment.

answer

Social Security number

question

An example of clinical data representation is a(n):

answer

ICD-9-CM code

question

A recent breakthrough in the development of the universal language to aid storage and transmission of web-based data is:

answer

XML

question

The primary purpose of the Continuity of Care Record(CCR) is to:

answer

Allow healthcare providers to readily acess information about a patient's healthcare at any point in time.

question

The exchange of igitized images such as X-rays, CT scans, and MRIs is supported by:

answer

DICOM

question

A statewide cancer surveillance system is an example of which of the NHII dimensions?

answer

Community

question

Each of the three dimensions (personal, provider, community) of information defined by the National Health Infrastructure (NHII) contains specific recommendations for:

answer

Core data elements

question

HEDIS is designed to collect:

answer

Administrative, claims, and health record review data.

question

A consumer interested in comparing the performance of health plans should review data from:

answer

Hispanic, non-Hispanic, unknown

question

A critical early step in designing an EHR is to develop a ___in which the characteristics of each data element are defined.

answer

Data dictionary

question

Most healthcare informative standards have been implemented by:

answer

Consensus

question

The federal law that directed the Secretary of Health and Human Services to develop healthcare standards governing electronic data interchange and data security is the:

answer

Health Insurance Portability and Accountability Act of 1996. (HIPPA)

question

Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallus valgus) is one purpose of:

answer

Vocabulary standards.

question

Critique this statement: The continuity care record contains only current clinical information.

answer

This is False statement as the CCR contains both future and past clinical information.

question

Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for:

answer

Performance improvement programs

question

The inpatient data set that has been incorporated into federal law and is required for Medicare reporting is the:

answer

Uniform Hospital Discharge Data Set.

question

Data that are collected from individual records and then combined are referred to as:

answer

Aggregate data.

question

The name of the government agency that has led the development of basic data sets for health records and computer databases is the:

answer

National Committee on Vital and Health Statistics.

question

Minimum data st in healthcare are developed to:

answer

Recommend common data elements to be collected in health records.

Health Data-Quiz 2,3,4

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