Domain 1 EHRs

Question 1

Patient’s admitting DOB and discharge summary DOB don’t match. What QUALITY element is missing?

Answer 1

Data Consistency

Question 2

Data grouped into meaningful categories according to a classification system are referred to as this type of data.

Answer 2

CODED
Coded data that is translated into standard nomenclature of classification so it may be aggregated, analyzed and compared

Question 3

RAPs

Answer 3

Resident Assessment Protocols. In Long term care this form is critical in care planning. The trigger conditions warrant additional assessments and review per MDS

Question 4

Authentication

Answer 4

Proves authorship. Ways to authenticate: electronic signature, handwritten signature or initials, biometric identifiers like fingerprints or retinal scan, unique passcode or identifier.

Question 5

LHR

Answer 5

Legal health record

Question 6

ICD-10-PCS character used as filler for an unknown value

Answer 6

Z

Question 7

RAI

Answer 7

Resident Assessment Instrument collects information of a resident’s risk factors and plan ongoing care of a resident in a long-term care facility. The MDS is a component of the RAI.

Question 8

SOAP note is part of what type of medical record?

Answer 8

POMR (problem- oriented medical record) 
S= subjective
O=objective
A= Assessment 
P=plan

Question 9

ERD

Answer 9

Entity-relationship diagram (ERD) it is a type of conceptual modeling. Most widely used. It visually represents and defines groupings of data and their relationship to each other. Very useful because it helps reduce errors.

Question 10

Degaussing

Answer 10

Degaussing removes unwanted magnetism. It is a way to destroy and electronic health record

Question 11

Destruction certification is kept how long by the facility who destroyed medical records.

Answer 11

Permanently

Question 12

What is a Mask used in a data dictionary

Answer 12

A mask tells the database what format to display a number. Example: xxx-xx-xxxx for social security or mm/did/yyyy for date of birth.

Question 13

Data governance vs information governance

Answer 13

Data governance is managing the INPUT of data.

Information governance is managing the OUTPUT of information.

Question 14

Data mapping

Answer 14

Data mapping links systems or data sets. A data map will have a “source” and a “target”. The source is the code or data set from which the map originated.

Question 15

Aggregate data

Answer 15

Aggregate data is used to develop information about groups of patients. It is data pulled from medical records.

Question 16

H&P for surgical patient can not be entered into the record no more than ____ days before surgery.

Answer 16

7

EVERY surgical patient needs a completed history& physical in their chart. Unless it was emergency surgery