Domain 3 Health Records and Data Content Flashcards
An audit of a hospital’s electronic health system shows that diagnostic codes are not being reported at the correct level of detail. This indicates a problem with
Data granularity requires that the attributes and values of data be defined at the correct level of detail for the intended use of the data (Sayles 2013, 53).
Which dimension of data quality is defined as “data that is free of errors?
Data that are free of errors are accurate. Typographical errors in discharge summaries or misspellings of names are examples of inaccurate data (LaTour et al. 2013, 175).
Which of the following materials is not documented in an emergency care record?
The emergency care record includes a pertinent history of the illness or injury and physical findings (Sayles 2013, 106–107).
An outpatient clinic is reviewing the functionality of a computer system it is considering purchasing. Which of the following datasets should the clinic consult to ensure all the federally required data elements for Medicare and Medicaid outpatient clinical encounters are collected by the system?
Uniform Ambulatory Care Data Set (Fahrenholz and Russo 2013, 295–298)UACDS
The following is documented in an acute-care record: “I was asked to evaluate this Level I trauma patient with an open left humeral epicondylar fracture. Recommendations: Proceed with urgent surgery for debridement, irrigation, and treatment of open fracture.” Where would this documentation be found?
(Consultation report) a consultation report includes the recommendations of a consulting physician who is requested to evaluate a patient (Sayles 2013, 93).
Both HEDIS and the Joint Commission’s ORYX programs are designed to collect data to be used for:
The ORYX Performance Measurement program collects quality data for hospitals and long-term care organizations and HEDIS collects data to measure physician performance (Sayles 2013, 155–156, 666–667).
Who is responsible for writing and signing discharge summaries and discharge instructions?
The physician principally responsible for the patient’s hospital care writes and signs the discharge summary (Fahrenholz and Russo 2013, 284).
What is the function of a consultation report?
The consultation report documents the clinical opinion of a physician other than the primary or attending physician (Sayles 2013, 93).
The discharge summary must be completed within ________ after discharge for most patients but within ________ for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for less than ________ hours.
(30 days/24 hours/48 hours)The discharge summary must be completed within 30 days after discharge for most patients but within 24 hours for patients transferred to other facilities. Discharge summaries are not always required for patients who are hospitalized for less than 48 hours (Fahrenholz and Russo 2013, 284)
The admitting data of Mrs. Smith’s health record indicated that her birth date was March 21, 1948. On the discharge summary, Mrs. Smith’s birth date was recorded as July 21, 1948. Which quality element is missing from Mrs. Smith’s health record?
(Data consistency)Consistent data will be the same each time it is reported or collected (Sayles 2013, 52).
What is the function of physician’s orders?
Document the physician’s instructions to other parties involved in providing care to a patient)Physician orders are the instructions the physician gives to the other healthcare professionals (Sayles 2013, 81).
Before healthcare organizations can provide services, they usually must obtain _____ by government entities such as the state in which they are located.
(Licensure)Compliance with state licensing laws is required in order for healthcare organizations to remain in operation (Sayles 2013, 71)
The hospital is revising its policy on medical record documentation. Currently, all entries in the medical record must be legible, complete, dated, and signed. The committee chairperson wants to add that, in addition, all entries must have the time noted. However, another clinician suggests that adding the time of notation is difficult and rarely may be correct since personal watches and hospital clocks may not be coordinated. Another committee member agrees and says only electronic documentation needs a time stamp. Given this discussion, which of the following might the HIM director suggest?
(Inform the committee that according to the Medicare Conditions of Participation, all documentation must be authenticated and dated)
All entries must be legible and complete and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished (42 CFR 482.24).
Reviewing the health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of ________ review.
(Quantitative)HIM professionals analyze medical records for any missing reports, forms, or required signatures and deletions. This is a quantitative analysis of the medical record (Sayles 2013, 350).
dentify where the following information would be found in the acute-care record: “PA and Lateral Chest: The lungs are clear. The heart and mediastinum are normal in size and configuration. There are minor degenerative changes of the lower thoracic spine.”
(Radiography report)Results of an x-ray interpretation by a radiologist are reported in a radiography report (Sayles 2013, 85–86).
