Ch 6 Data Management Flashcards
True/False: a data element is a single or individual fact that represents the smallest unique subset of larger data.
True
Critique each statement to determine the one that demonstrates the intent of a data set.
A recommended list of data elements that support a specific healthcare industry
The intent and purpose of the creation of a data dictionary is to:
Create support for structured data collection
The 2 most commonly used database in healthcare are:
Relational & object oriented databases
True/false: an index creates a definition for data elements within a database
False
True / false: there is usually only one source of data within a healthcare organization
False
Which term is defined as principal & oversight to manage the information that is produced by the different systems within a healthcare organization?
Information governance
Select the process that can help organizations evaluate the current state of best practices with data management, gaps, and areas of opportunity based on risk, strategy, and operations of the organization.
Information governance adoption model
Define the principle of integrity
Create assurances that the data generated and maintained by an organization maintains authenticity & reliability
True/false: an information governance initiative is a project within a healthcare organization led by middle level leadership
False
True/ false: information governance and data governance are the same concept and can be used interchangeably.
False
Distinguish which of the following are components of AHIMA’s principles of information governance.
Accountability and integrity
Compliance
create a process for ensuring that all the information meets requirements of appropriate laws & regulations, standards & organizational policies
Dispositions
create processes for secure & appropriate destruction of info that is no longer needed to be maintained by the healthcare organiztion
Retention
create a process for proper preservation of information based on requirements from regs, accrediting orgs and company policy
Transparency
create a clear & open documentation process for the information governance strategy & activities within a healthcare org. instruments & clinical info systems
accountability
create authority over the information governance process within an organization
When creating requirements of documentation for hospital bylaws, which of the following should be evaluated?
the documentation needs based on accrediting bodies
The 2 most commonly used database in healthcare are:
relational and object oriented databases
Define the principle of integrity
create assurances that the data generated & maintained by the organization maintains authenticity & reliability
T/F Data granularity is where the data collected is collected at a level of detail that meets the needs of the healthcare org
True
Recommend a guideline for maintaining integrity in the health record.
Prohibiting the entry of false info into any of the healthcare orgs health records
Which term is defined as principles & oversight to manage the information that is produced by the different systems within a healthcare org?
Information governance
True/ False Without proper definition & requirements of data quality & data collection it is challenging for healthcare org to hold healthcare providers accountable for documentation?
True
Which of the following data quality characteristics means all data items are included in the information collected?
Comprehensiveness
True/ False Information governance & data governance are the same concept & can be used interchangeably
False
True/ false An information governance initiative is a project within a healthcare org led by middle level leadership
False
True/ False When creating bylaws for the medical staff, expectations of data quality should be established within the bylaws.
True
True/ False A data element is a single or individual fact that represents the smallest unique subset of larger data.
True
Healthcare organization do not need to evaluate the purpose of data collection for assuring data quality.
False
Distinguish which of the following is a goal of a CDI program.
Identify & clarify missing, conflicting, or nonspecific physician documentation related to diagnoses and procedures
The intent & purpose of the creation of a data dictionary is to:
Identify the data elements that you want to collect
Identify which of the following are the 4 data quality management domains.
Application, collection, warehousing, and analysis
Identify the 2 types of queries used in clinical documentation integrity.
Paper and electronic
True/ False Data sharing is needed regardless of the info system used.
True
True/ False The response from a query will never go into the health record as it is just communication between the CDI prof & the provider.
False
Select the process that can help org evaluate the current state of best practices with data management, gaps and areas of opportunity based on risk, strategy and operations of the org.
Information governance adoption model
True/ False Data stewardship is practices established to ensure the knowledgeable and appropriate use of data derived from individuals personal health information
True
Critique each statement to determine the one that demonstrates the intent of a data set.
A recommended list of data elements that support a specific healthcare industry
Distinguish which of the following are components of AHIMA’s principles of information governance
Accountability and integrity
True/ False When creating provider contracts healthcare org should not define disciplinary actions in the event that the contract requirements ae not met.
False
Identify which of the following describes what information assets are
Information collected by a healthcare organization that has value
True/ False When creating provider contracts healthcare orgs should not define disciplinary actions in the event that the contract requirements are not met.
False
True/ False Data sharing is needed regardless of the info system used.
True
True/ False There is usually only one source of data within a healthcare organization
False
True/ False An index creates a definition for data elements within a database.
False
AHIMA has created 8 principles to help orgs create_________ within their organization.
Information governance
Critique the following statement: when writing a query for clinical documentation questions, the physician should be told specifically what needs to be written.
This is false statement as queries should not lead the physician
Recommend a strategy that will help a healthcare org use personal health information in a knowledgeable way.
Data stewardship
The way that information is used is spelled out in an ________
Use case
To identify 10 pts who had an appendectomy, the _______ should be consulted.
Procedure index
The term that describes data that define & characterize other data within an electronic system is ________
Metadata
The ________ characteristic of quality data means the data is completely free from any errors.
Accuracy
A visual process to understand the data being collected in 2 different systems & how it is linked to one another is known as _______
Data mapping
________ is the process of extracting info stored in structured data formats within a database.
Data mining
Identify the data characteristic that is met when documenting the specific height of a pt within the health record.
Precision
The quality characteristics that address the level of detail is _______
Granularity
The capability for 2 or more electronic systems to communicate and exchange information electronically is known as _____
Interoperability
Identify a collection of data that is organized in a manner to be accessed, managed, reported and updated electronically.
Database
Authorship validation is one part of ______
Data integrity
Recommend a data set to collect uniform data across the United States for inpatient pt stays.
Uniform Hospital Discharge Data Set (UHDDS)
A _______ is a communication tool used during clinical documentation integrity to communicate between a clinical documentation integrity professional and the provider.
Query
______ includes the process of data governance, pt identification, authorization validation, amendments and record corrections & audit validation
Data integrity
The data set that collects data on the provider, place of encounter, reason for encounter, problem, diagnosis, assessment, therapeutic services, preventative services and disposition
Uniform Ambulatory care data set (UACDS)
A health information manager took the 3 elements, blood pressure, weight and cholesterol to analyze for potential indicators of a heart attack. The combined data is referred to as ______
Information
The healthcare org needs to create a unique numbering system to identify all forms used within the healthcare org. It needs to create a
Form tracking system
A pts birthday and gender documented in the healthcare record are examples of a data______
Element
The data characteristics that refer to promptly entering up to date info into the pts medical record is ______
Timeliness
Identify a principal of data stewardship as defined by the National Committee on Vital & Health Statistics
Individuals rights
An example of a clinical documentation integrity tool is ______
Computer assisted coding
The HIM director was asked to justify the use of IGAM. The appropriate response is ______
It helps evaluate an information governance initiative
The processes & functions created by an org to help plan, organize & coordinate people, processes, technology, and content to manage info systems is known as ____
Enterprise info management
_____ define the process for documentation within a health record for all members of the workforce.
Hospital bylaws
The term that describes data that define & characterizes other data within an electronic system is ______
Meta data
The process that focuses on the improving the quality & integrity of pt data while supporting timely coding & reimbursement is known as _______
Clinical documentation integrity
Identify which of the following is an example of an electronic data source in healthcare
Radiologic info system
Creating a graph is an example of _______
Data visualization
Which of the following documents defines how health records & documentation are assembled & authenticated within the hospital?
Medical staff bylaws
The process of completing an inventory of all electronic systems that create, transmit, & store health information is known as _______
System characterization
A specific fact about a pt is known as _______
Data element
Will a registration staff member,is trying to enter Arizona as a pts state of residence. Every time he starts typing it. Arkansas pops up. Identify the issue preventing Will from entering the correct state
The data dictionary is built to accept only 2 characters for this field (postal code for state)
Will begins to key in the pt’s phone number 867-530-6967 & only gets as far as 867-530-69 when the field will not accept any more characters. Identify this issue
The phone number field is built to accept only 10 characters which would account for the numbers with no dashes
