Domain 1 Flashcards
In designing a new form or computer view, the designer should be most driven by? A. Needs of the users B. what information should be coded C. Authors of entries in a health record D. Needs of the patients
A. Needs of the user
The needs of the user should always be the primary concern
What data entry software system do home health agencies use?
A. Incidence-only population-based registry
B. Home health agency
C. HAVEN (Home Assessment Validation and Entry)
D. A release of information company
C. HAVEN (Home Assessment Validation and Entry) is available on the OASIS website
Which rate is used to compare the number of inpatient deaths to the total number of inpatient deaths and discharges?
A. Net hospital death rate
B. Fetal/newborn/maternal hospital death rate
C. Gross hospital death rate
D. Adjusted hospital death rate
C. Gross hospital death rate is figured by dividing the total number of discharges by the total number of deaths
In a problem oriented health record, problems are organized: A. In alphabetical order B. In numeric order C. By date of onset D. None of the above
B. In numeric order
Problems are always organized by numeric order
A health information technician is responsible for designing a data collection form to collect data on patients in an acute care hospital. The first resource that should be used is: A. UHDDS B. UACDS C. MDS D. ORYS
A. UHDDS
Uniform Hospital Discharge Data Set is the first resource used
In long term care the residents care plan is based on data collected in what system? A. UHDDS B. OASIS C. MDS D. HEIDS
C. MDS
Minimum Data Set is considered the minimum amount needed to know about any one person, per Medicare guidelines, to provide appropriate, individualized care to that person
Which of the following is NOT a characteristic of high quality healthcare? A. Data relevancy B. Data currency C. Data consistency D. Data accountability
D. Data accountability is not a characteristic of high quality healthcare
The RHIT supervisor for the filing and retrial section of Community Clinic is developing a staffing schedule for the year. The clinic is open 260 days per year and has an average of 500 clinic visits per day. The standard for filing record is 50 per hour. For retrieving records it is 40 per hour. How many filing hours will be required daily to retrieve and file records for each clinic day? A. 10 hours per day B. 11.11 hours per day C. 12.5 hours per day D. 22.5 hours per day
D. 22.5 hours per day Calculation is (500/50) + 500/40) = 22.5 hours per day
Term used to articulate the number of inpatients present at any one time in a healthcare facility? A. Average daily census B. Census C. Inpatient service day D. Length of stay
B. Census
Do not be fooled into average daily census which is the mean number of patients
Which of the following material is NOT documented in an emergency record?
A. Time and means of patient arrival
B. Patients instruction at discharge
C. Patient complete medical history
D. Emergency care administered before arrival at the facility
C. Patient complete medical history is NOT documented in an emergency record
What is the difference between data and information?
A. Data represents basic facts, information provides meaning
B. Data is expressed in numbers, information is expressed in words
C. Information must be kept confidential, data can be shared
D. Information is about people, data is about things
A. Data represents basic facts, information provides meaning
Data is factual without giving any meaning to the facts. Information offers meaning and explanation
Which term is used to describe the number of inpatients present at the census taking time each day PLUS the number of patients that were both admitted and discharged after the census taking time the previous day? A. Inpatient occupancy rate B. Bed count C. Average daily census D. Daily inpatient census
D. Daily inpatient census
Which rate describes the probability of occurrence of a medical condition in a population over a period of time? A. Mortality B. Morbidity C. Incidence D. Prevalence
C. Incidence
Incidence in epidemiology is a measure of the probability of occurrence of a given medical condition in a population within a specified period of time. Although sometimes loosely expressed simply as the number of new cases during some time period, it is better expressed as a proportion or a rate with a denominator
Patient care managers use the data and information documented in the health record to:
A. Evaluate patterns and trends in patient care
B. Provide direct patient care
C. Generate patient bills and third party claims for reimbursement
D. Determine the extent and effect of occupational hazards
A. Evaluate patterns and trends in patient care
An outpatient clinic is reviewing the functionality of an EHR it is considering purchasing. Which of the following data sets should the clinic consult to ensure that all of the federally recommended data elements for Medicare and Medicaid outpatients are collected by the system? A. DEEDA B. EMEDS C. UACDS D. UHDDS
C. UACDS
Uniform Ambulatory Care Data Sets include patient specific items for outpatient care
The HIM department recently performed an audit of health records. The audit showed that for the 10,000 records filed there was a 7 percent error rate. The national average of each misfile is $200. What is the labor cost for the department for handling these misfiled reports? A. $1,400 B. $14,000 C. $140,000 D. $285,714
C. $140,000
The math is: (10,000 x 0.07) x 200 = $140,000
The home health prospective payment system (HHPPS) uses the \_\_\_\_\_\_\_\_\_ data set for patient assessments. A. UHDDS B. OASIS c. HCPCS D. MDS
B. OASIS
Outcome and Assessment Information Set
The Outcome and Assessment Information Set (OASIS) data are used to assess the \_\_\_\_\_\_\_\_\_\_\_\_\_ of home health services A. Quality B. Accuracy C. Outcome D. Objective
C. Outcome
The data set designed to organize data for public release about the outcomes of care is \_\_\_\_\_\_\_\_\_? A. HEDIS B. UHDDS C. MDS D. HCPCS
A. HEDIS
Healthcare Effectiveness Data and Information Set
In Long Term Care “LTC”, the residents’s care plan is based on data collected in the \_\_\_\_\_\_\_\_? A. MDS version 2.0 B. Data dictionary C. NCHS D. None of the above
A. MDS version 2.0
Minimum data set version 2.0
Which of the following provides a standardized vocabulary for facilitating the development of computer-based records? A. HCPCS B. UHDDS C. OASIS D. HEDIS
A. HCPCS
The Healthcare Common Procedure Coding System-is a set of health care procedure codes based on the American Medical Association’s Current Procedural Terminology (CPT)
Community Hospital has 250 patients in the hospital at midnight on May 1st. They admit 30 patients on May 2nd. The hospital discharged 40 patients, including deaths, on May 2nd. Two patients were both admitted and discharged on May 2nd. What is the total number of inpatient service days for May 2nd? A. 240 B. 242 C. 280 D. 320
B. 242
A unit of measure that reflects the services received by one inpatient in a 24-hour period is called an inpatient service day. The number of inpatient service days for a 24 hour period is equal to the daily inpatient census - that is, one service day for each patient treated. The calculation is: [(250+30) - 40] + 2 = 242
Community Hospital has more than 100 clinical databases. The Data Quality Committee is studying the comparability among the databases. The data elements and data definitions are cataloged for each database. What would be the next logical step in determining the degree of comparability among the database?
A. Identify the operating system for each database and determine if they are similar to each other.
B. Select a representative set of data elements and track these across the database to identify consistencies and differences.
C. Identify the network capability of each of the databases so that data can be exchanged.
D. Determine the volume and type of data stored within each database so that a repository of similar data can be developed.
B. Select a representative set of data elements and track these across the database to identify consistencies and differences.
Once hospital discharge abstract systems were developed and their ability to provide comparative data to hospitals was established it became necessary to develop: A. Data sets B. Data elements C. Electronic data interchanged D. Bills of mortality
A. Data sets
Which of the following provides a system for classifying morbidity and mortality information for statistical purposes? A. CPT B. DSMMD 4th edition C. HCPCS D. ICD-10-CM
D. ICD-10-CM
The international Classification of Diseases - 10th Revision-Clinical Modification
After the type of cases to be included in a registry have been determined, what is the next step in data acquisition? A. CPT B. defining C. Abstracting D. Finding
C. Abstracting
Which of the following use data from the MDS for long term care?
A. Centers for Medicare and Medicaid Services
B. Home health hospice agencies
C. Home health agencies
D. Rehabilitation facilities
A. Centers for Medicare and Medicaid Services
CMS uses the Minimum Data Set for long term care
A Health Record Technician has been asked to review the discharge patient abstracting module of a proposed new EHR. Which of the following data sets would the technician consult to ensure the system collects all federally required discharge data elements for Medicare and Medicaid inpatients in an acute-care hospital?
A. Select a representative set of data elements and track these across the database to identify consistencies and differences.
B. Identify the network repeatability of each of the databases so that the data can be exchanged
C. Determine the volume and type of data stored within each database so that the repository of similar data can be developed
D. All of the above
C. Determine the volume and type of data stored within each database so that the repository of similar data can be developed
A critical early step in designing an EMR “electronic medical record” is to develop \_\_\_\_\_\_\_\_\_\_\_ in which the characteristics of each data element are defined. A. Data currency B. Data dictionary C. Minimum Data Set D. Classification of patients
B. Data dictionary
A core data set developed by the American Society for testing and materials (ASTM) to communicate a patient’s past and current health information as the patient transitions from one care setting to another is \_\_\_\_\_\_\_? A concept table B. Common data elements C. Core Data Elements D. Continuity of Care Record
D. Continuity of Care Record
