Domain 1 Flashcards
Data that have been grouped into meaningful categories according to a classification system are referred to as this type of data:
a. Research
b. Reference
c. Coded
d. Demographic
Coded
To meet meaningful use standards, Anywhere Hospital is implementing a document imaging system and electronic document management system. This is an interim step before full implementation of computerized provider order entry and point-of-care documentation. This step-by-step process is part of Anywhere Hospital’s:
a. Migration plan
b. Strategic plan
c. Bylaws update
d. Regulatory update
Migration plan
A strategic plan that identifies applications, technology, and operational elements needed for the overall information technology program in a healthcare entity is a(n):
a. Implementation plan
b. Information technology plan
c. Migration path
d. Transition strategy
Migration path
When defining the legal health record in a healthcare entity, it is best practice to establish a policy statement of the legal health record as well as a:
a. Case mix index
b. Master patient index
c. Health record matrix
d. Retention schedule
Health record matrix
Bob Jones is considering contractors for his company’s medical benefits, and he is reviewing health plans from two different entities. Which of the following databases should he consult to compare the performance of the two health plans?
a. HEDIS
b. OASIS
c. ORYX
d. UHDDS
HEDIS
A patient has HIV with disseminated candidiasis. What is the correct code assignment?
B20 Human immunodeficiency virus [HIV] disease B37.0 Candidal stomatitis Oral thrush B37.7 Candidal sepsis Disseminated candidiasis Systemic candidiasis B37.89 Other sites of candidiasis Candidal osteomyelitis a. B20, B37.0 b. B37.7, B20 c. B20, B37.7 d. B20, B37.89, B37.7
B20, B37.7
While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on the:
a. Reason for admission
b. Activities of daily living
c. Discharge diagnosis
d. Reason for encounter
Reason for encounter
Two clerks are abstracting data for a registry. When their work is checked, discrepancies are found between similar data abstracted by the two clerks. Which data quality component is lacking?
a. Completeness
b. Validity
c. Reliability
d. Timeliness
Reliability
A Staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy and is now removed via a percutaneous nephrostomy tube. What is the root operation performed for this procedure?
a. Destruction
b. Extirpation
c. Extraction
d. Fragmentation
Extirpation
Which of the following materials are required elements in an emergency care record?
a. Patient’s instructions at discharge and a complete medical history
b. Time and means of the patient’s arrival, treatment rendered, and instructions at discharge
c. Time and means of the patient’s arrival, patient’s complete medical history, and instructions at discharge
d. Treatment rendered, instructions at discharge, and the patient’s complete medical history
Time and means of the patient’s arrival, treatment rendered, and instructions at discharge
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. Continuity of care record
b. Minimum Data Set
c. Ambulatory Care Data Set
d. Uniform Hospital Discharge Data Set
Continuity of care record
The insured party’s member identification number is an example of this type of data:
a. Demographic data
b. Clinical data
c. Certification data
d. Financial data
Financial data
Sue is updating the data dictionary for her organization. In this data dictionary, the data element name is considered which of the following?
a. Master data
b. Metadata
c. Structured data
d. Unstructured data
Metadata
Assign codes for the following scenario: A 35-year-old male is admitted with esophageal reflux. An esophagoscopy and closed esophageal biopsy was performed.
K20.9 Esophagitis, unspecified
K21.0 Gastro-esophageal reflux disease with esophagitis
K21.9 Gastro-esophageal reflux disease without esophagitis
Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Gastrointestinal System Inspection Upper Intestinal Tract Via Natural or Artificial Opening Endoscopic No Device No Qualifier 0 D J 0 8 Z Z
Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Gastrointestinal System Excision Esophagus Via Natural or Artificial Opening Endoscopic No Device No Qualifier 0 D B 5 8 Z X
Section Body System Root Operation Body Part Approach Device Qualifier Medical and Surgical Gastrointestinal System Excision Esophagus Via Natural or Artificial Opening Endoscopic No Device No Qualifier 0 D B 5 8 Z Z a. K21.9, 0DB58ZX b. K20.9, 0DB58ZZ c. K21.0, 0DB58ZX d. K21.9, 0DJ08ZZ, 0DB58ZX
K21.9, 0DB58ZX
Which of the following would be the best approach in starting a data governance program?
a. Focus on one or a few small business imperatives
b. Begin with developing policies and procedures
c. Identify HIPAA requirements
d. Establish success metrics
Focus on one or a few small business imperatives
