Domain 1 Data Content, Structure, And Information Governance Flashcards
1. Which of the following data sets would be the most helpful in developing a hospital trauma date registry? A. DEEDS B. MDS C OASIS D. UACDS
A. DEEDS
2. Dr jones comes into the HIM department and requests that the HIM director provides a list of his records from the previous year that show a principal diagnosis of myocardial infarction. What would the HIM director use to provide this list? A. A disease index B. A mater patient index C. An operative index D. A physician index
A. A disease index
3. Community Hospital’s HIM department conducted a random sample of 150 inpatient health records to determine the discharge summary completion timelines rate. Thirteen discharged were determined to be out of compliance with completion standards. Which of the following percentages represents the timelines rate for discharge summaries at Community Hospital? A. 8.7% B. 9.5% C. 41.5% D. 91.3%
D. 91.3%
4. Activities of daily living (ADL) are components of A. OASIS-C B. UHDDS C. UACDS D. ORYX and RAPs
A. OASIS-C
- Which of the following documentation must be included in a patients’s health record prior to performing a surgical procedure?
A. Consent for operative procedure, anesthesia report, surgical report
B. Consent for operative procedure, history, physical examination
C. History, physical examination, anesthesia report
D. Problem list, history, physical examination
B. Consent for operative procedure, history, physical examination
- Which of the following should be avoided when designing forms for an electronic document management system (EDMS)?
A. Color borders around the edge of a forma
B. Mnemonic descriptor used for non barcode recognition engine
C. Quarter-NCHS border on each side of document without bar code
D. Shading of bars or lines that contain text
D. Shading of bars or lines that contain text
7. AHIMA’s retention standards recommend that the master patient index be maintained: A. For at least 5 yeats B. For a least 10 years C. For at least 25 years D. Permanently
D. Permanently
8. A hospital’s EHR defines the expected values of the gender data element as female, male, and unknown. This type of specificity is known as? A. Data precision B. Data consistency C. Data granularity D. Data comprehensiveness
A. Data precision
- Cancer registries are maintained by hospitals:
A. By federal law or state law
B. Voluntarily or by state law
C. Voluntarily or by federal law
D. By mandate from the American college of Surgeons
B. Voluntarily or by state law
10. Which of the following reports includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed? A. Anesthesia report B. Laboratory report C. Operative report D. Pathology report
C. Operative report
- The hospital currently has a hybrid health record. Nurses and clinicians are recording bedside documentation electronically in a clinical documentation system, while most other documentation, such as physician progress notes and orders, are paper based and stored in a paper health record, making retrieval of the complete record after discharge difficult and risking the record’s integrity. Given these circumstances, which of the following should the HIM director implement to alleviate these problems and preserve the efficiencies of an electronic record?
A. Print out all electronic data postdischarge and file with the rest of the paper record
B. Microfilm all electronic data and link to the paper record
C. Digitally scan all paper records postdischarge, and integrate and index these into the existing electronic document management system
D. Do not scan any of the paper records
C. Digitally scan all paper records post discharge, and integrate and index these into the existing electronic document management system
- In a routine health record quantitative analysis review, it was found that a physician dictated a discharge summary on 1/29/20xx. Because of unexpected complications, however, the patient was discharged two days after the discharge summary was dictated. What would be the best course of action in this case?
A. Request that the physician dictate an addendum to the discharge summary
B. Have the record analyst note the date discrepancy
C. Request that the physician dictate another discharge summary
D. File the record as complete because the discharge summary includes all of the pertinent patient information
A. Request that the physician dictate an addendum to the discharge summary
The hospital is revising its policy on health record documentation. Currently, all entries in the health record must be legible, complete, dated and signed. The committee chairperson want to add that all entries must have the time noted. However, another clinician suggests that adding the time of notation is difficult and rarely may be correct because personal watches and the hospital clocks may not be coordinated. Another committee member agrees and say that only electronic documentation needs a time stamp. Given this discussion, which of the following might the HIM director suggest?
A. Suggest that only hospital clock time be noted in clinical documentation
B. Suggest that only electronic documentation have time noted
C. Inform the committee that according to the Conditions of Participation, all documentation must include date and time
D. Inform the committee that according to the Conditions of Participation, only medication orders must include date and time
C. Inform the committee that according to the Conditions of Participation, all documentation must include date and time
14. Identify the report where the following information would be found: HEENT: reveals the tympanic membranes nares and pharynx to be clear. No obvious head trauma. CHEST: good bilateral chest sounds.? A. Discharge summary B. Health history C. Medical laboratory report D. Physical examination
D. Physical examination
- You are the director of HIM at Community Hospital. A physician has asked for the total number of appendectomies that he performed at your hospital last year. What type of data will you provide the physician with?
A. Patient-specific data
B. Aggregate data
C. Operating room data
D. Nothing—you cannot obtain this data after the fact
B. Aggregate data
