Domain 1 - Information Governance Flashcards
19% of exam
A method of documenting nurses’ progress notes by recording only abnormal or unusual findings or deviations from the prescribed plan or care is called:
A - Problem-oriented progress notes
B - Charting by exception
C - Consultative notations
D - Open charting
B - Charting by exception
A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis, and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured appendix was discovered. The chief complaint was:
A - Abdominal pain
B - Cholelithiasis
C - Exploratory laparoscopy
D - Ruptured appendix
A - Abdominal pain
Mrs. Smith’s admitting data indicates that her birth date is March 21, 1948. On the discharge summary, Mrs. Smith’s birth date is recorded as July 21, 1948. Which data quality element is missing from Mrs. Smith’s heath record?
A - Data accuracy
B - Data consistency
C - Data accessibility
D - Data comprehensiveness
B - Data consistency
The discharge summary must be completed within ___ after discharge for most patients but within ___ for patient transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for fewer than ___ hours.
A - 30 days, 48 hours, 24 hours
B - 14 days, 24 hours, 48 hours
C - 14 days, 48 hours, 24 hours
D - 30 days, 24 hours, 48 hours
D - 30 days, 24 hours, 48 hours
Which of the following is an acceptable means of authenticating a record entry?
A - The physician’s assistant electronically signs for the physician.
B - The HIM clerk electronically signs using the physician’s login.
C - The charge nurse electronically signing for the physician.
D - The physician personally signs the entry electronically.
D - The physician personally signs the entry electronically
If an analyst is studying the wait times at a clinic and the only list of patients available is on hard copy, which sampling technique is the easiest to use?
A - Survey sampling
B - Systematic sampling
C - Cluster sampling
D - Stratified sampling
B - Systematic sampling
In a long-term care setting, these are problem-oriented frameworks for additional patient assessment based on problem identification items (triggered conditions):
A - Resident Assessment Protocols (RAPs)
B - Resident Assessment Instrument (RAI)
C - Utilization Guidelines (UG)
D - Minimum data sets (MDS)
A - Resident Assessment Protocols (RAPs)
What data model is most widely used to illustrate a relational database structure?
A - Entity-relationship diagram (ERD)
B - Object model
C - Relational model
D - Unified medical language system (UMLS)
A - Entity-relationship diagram (ERD)
Alex, an HIM analyst, review the record of Patty Eastly, a patient in the facility, to ensure that all documents are complete and signatures are present. This is an example of a:
A - Closed review
B - Qualitative review
C - Concurrent review
D - Delinquent review
C - Concurrent review
What type of information makes it easy for hospitals to compare and combine the contents of multiple patient health records?
A - Administrative information
B - Demographic information
C - Progress notes
D - Uniform data sets
D - Uniform data sets
Which of the following materials are required elements in an emergency case record?
A - Patient’s instructions at discharge and a complete medical history.
B - Time and means of the patient’s arrival, patient’s complete medical history, 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
B - Time and means of the patient’s arrival, patient’s complete medical history, and instructions at discharge
Pam is a nursing supervisor in the newborn intensive care unit. During her shift, several parents of newborns in the unit are visiting. The neonatologist has also recently been in and has provided orders for several of the newborns. Because of the current workload, another nurse in the unit, Jackie, has asked Pam to help her complete the orders. Pam is asked to administer a medication to one of the newborns that Jackie has already retrieved for the patient. Jackie tells Pam that she has doublechecked the medication both through barcoding and with the order. Before Pam administers the medication, she scans both the medication and the newborn’s patient ID band and learns she has the incorrect medication for this patient. Pam does not administer that medication but goes back to the order and, through the proper steps, administers the correct medication. Based on this scenario, which of the following occurred?
A - Time-out
B - Serious event
C - Sentinel event
D - Near miss
D - Near miss
In assessing the quality of care given to patients with diabetes mellitus, the quality team collects data regarding blood sugar levels on admission and on discharge. These data are called a(n):
A - Indicator
B - Measurement
C - Assessment
D - Outcome
A - Indicator
Which of the following is the unique identifier in the relational database patient table?
A - Patient last name
B - Patient last and first name
C - Patient date of birth
D - Patient number
D - Patient number
Which of the following is used by a long-term care facility to gather information about specific health status factors and includes information about specific risk factors in the resident’s care?
A - Care management
B - Minimum data set
C - Outcomes and assessment information set
D - Core measure abstracting
B - Minimum data set
Dr. Collins, admitted Mr. Smith to University Hospital. Blue Cross Insurance will pay Mr. Smith’s hospital bill. Upon discharge from the hospital, who owns the health record of Mr. Smith?
A - Mr. Smith
B - Blue Cross
C - University Hospital
D - Dr. Collins
C - University Hospital
Jane Smith emailed her physician, Dr. Ward, to express concern about an abnormal lab value report she received during her last physical exam. Dr. Ward responded to Jane’s email by further explaining the lab test and value meanings and then offered various treatment options. How should this email correspondence be handled?
A - Since this is an email correspondence, the facility has no responsibility to keep it as part of the patient’s medical record.
B - Since this email correspondence relates to communication between a physician and a patient and includes PHI, the facility should include the email in the patient’s medical record.
C - Since this is an email correspondence, it should be kept in a separate social media file within the health information management department.
D - Since this is an email correspondence, it should be immediately deleted from the server and the physician should be disciplined for discussing PHI related topics via social media.
B - Since this email correspondence relates to communication between a physician and a patient and includes PHI, the facility should include the email in the patient’s medical record.
Derek, an HIM technician, reviews each record in the EHR system upon discharge of the patient to ensure that the system correctly assigned all documentation to the correct tab category (for example, all lab reports under the lab tab and x-ray reports under the radiology tab). This system utilizes which format for its patient care record?
A - Integrated
B - Practice-oriented
C - Chronological
D - Source-oriented
D - Source-oriented
A local skilled nursing facility has been working to improve the quality of care it provides to residents. Facility staff have engaged in several PI initiatives recently, and the facility’s internal data shows an improvement in quality metrics. The facility administrator is pleased with these findings but is also interested in determining how this facility is performing in contract to other nearby skilled nursing facilities. Which of the following should the HIM professional use to inform management on how the facility compares to other in the area?
A - Comparative performance data
B - Internal infection reporting
C - Master patient index
D - Provider performance data
A - Comparative performance data
The insured party’s member identification number is an example of which type of data?
A - Demographic data
B - Clinical data
C - Certification data
D - Financial data
D - Financial Data
In a relational database, which of the following is an example of a many-to-many relationship?
A - Patients to hospital admissions
B - Patients to consulting physicians
C - Patients to hospital health records
D - Primacy care physician to patients
B - Patients to consulting physicians
Borrowing record entries from another source as well as representing or displaying past documentation as current are examples of a potential breach of:
A - Identification and demographic integrity
B - Authorship integrity
C - Statistical integrity
D - Auditing integrity
B - Authorship integrity
The process by which a person or entity who authored an EHR entry or document seeks to validate that they are responsible for the data contained within it is called:
A - Endrosement
B - Confirmation
C - Authentication
D - Consent
C - Authentication
Anywhere Hospital has mandated that the Social Security number will be displayed in the XXX-XXX-XXXX format for their patients. This is called an example of the use of a:
A - Wildcard
B - Mask
C - Truncation
D - Data definition
B - Mask
