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196 Cards in this Set
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- 3rd side (hint)
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What is the crucial first step for effective management of data and it is also performed continuously as needed. |
Planning |
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What happens when planning is not performed? |
It is difficult to make effective decisions and determine the success of a project or program. |
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Identification of what in data management plan is crucial? |
Goals and objectives Budget and time constraints Stakeholders |
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In HIM planning, what should the HIM professional have an understanding of? |
Function of the health record. Understanding of the significant healthcare data sets and standards. |
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Critical tasks performed by RHITs |
Participate in the data management plan Develop data management plan Maintain data dictionaries |
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What does participating in the data management plan include: |
Determining data elements. Assemble components. Set time-frames. |
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What are the foundation of the EHR |
Data elements |
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What is needed to maintain high-quality data that leads to high-quality information and decisions |
Data management plans |
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What does AHIMA define data dictionaries as?? |
Descriptive list of names, definitions, and attributes of data elements to be collected in an information system or database. |
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Recommended or required summary of data elements which apply to a particular activity. |
Data Set |
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Example of data set |
Address which consists of: Name Street or post office number City State Zip Code |
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UHDDS |
Uniform Hospital Data Discharge Set |
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Can one data set be apart of another? |
Yes |
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What is the UHDDS |
Data Set |
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Examples of different data sets |
DEEDS EMDS HEDIS IRF-PAI MDS NEDSS NHAMCS OASIS UACDS |
There are 9 |
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DEEDS |
Data Elements for Emergency Dpt Systems Included 156 data elements for hospital emergency rooms. |
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EMDS |
Essential Medical Data Set Compliments DEEDS incorporating medical history elements into ER data collection. |
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HEDIS |
Healthcare Effectiveness Data and Information Set Tool used by health plans in American which contains performance measures on important dimensions of car and service. |
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IRF-PAI |
Inpatient Rehabilitation Facility - Patient Assessment Instrument |
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MDS |
Minimum Data Set For long-term care and Resident Assessment Protocols |
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NEDSS |
National Electronic Disease Surveillance System |
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NHAMCS |
National Hospital Ambulatory Medical Care Survey |
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OASIS |
Outcome and Assessment Information Set used in Home health |
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UACDS |
Uniform Ambulatory Care Data Set |
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What is an accepted way of doing a task or a guide for expected performance? |
Standard |
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What are standards that have been set to ensure uniformity of data exchange? |
Accepted formats |
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What are the different forms of patient data |
Text Digital Image Electrical tracings Sound recordings |
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What is a tool organizations can use to help ensure data accuracy? |
Data Dictionary |
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What is a dynamic document that is evaluated as data needs change or grow. |
Data Dictionary |
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Examples of practices that help organizations maintain their data dictionaries and data integrity |
1. Know the data 2. Map data across ALL systems 3. Develop a data quality management process. 4. Comply with regulations and standards. 5. Ensure accuracy of data collection and reporting. 6. Establish change management policies and procedures. 7. Develop active and ongoing user education and training |
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What is the principal repository for data and information about the healthcare services provided to an individual patient. Documents who, what, when, where, why, and how of patient care. |
Health Record |
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What is the purpose and function of the health record? |
Review of systems |
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Promotes data integrity by supporting the adoption and use of consistent data elements and terminology within health IT systems |
Data Dictionary |
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Responsibilities and tasks related to maintaining data dictionaries include all but: A. Ensure that data elements are unique and not shared with other health IT systems B. Identifying and promoting clear and valid definitions for enterprise data. C. Assessing and resolving data integrity issues. D. Identifying and further defining required validation rules to be applied when capturing. |
A. |
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Is the purpose of a health record to educate healthcare professionals primary or secondary purpose? |
Secondary |
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What involves uniform standardization of practices, policies, and procedures that results in reliable and consistent data. |
Health Data Collection |
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What are examples of abstract information found in health records |
Coding Research Physician deficiencies |
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What does collecting information from a variety of sources allow HIM professionals to do? |
Validate the accuracy of information |
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What promotes inter-operability and automates data sharing? |
Metadata registry aka data dictionary |
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What is data derived directly from a source such as data in the health record. |
Primary data |
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What is data taken from the primary source and entered into registries and databases? |
Secondary data |
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What is another name for aggregate data |
Collective data |
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What is another name for discrete data |
Separate or Individual data |
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Structure data |
Limited character fields |
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Unstructured data |
Free Text |
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Different methods data can be stored |
Numerical Categorical Logical Coded |
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Different types of data |
Audio Video Digital Analog Vector graphic Photographic |
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What is another name for vector graphic data |
Tracings |
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What is data and an example |
Raw facts Ex. Patient height and weight |
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What is information |
Processed data |
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What type of data is a patients weight and height |
Data
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Data derived from a secondary sourced; based on analysis of data derived from an aggregate of primary sources |
Primary Data |
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A patients BMI is an example of what? Why? |
Information
Because it is derived from the patient's height and weight. |
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What is processed data? |
Information |
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A patient's age is an example of what? |
Primary Data |
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Data that is derived from a secondary source; based on analysis of data derived from an aggregate of primary sources |
Secondary Data |
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The average age when adult onset diabetes is first diagnosed in women is an example of what? |
Secondary Data |
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Collective Data |
Aggregate Data |
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The total number of pts admitted to the CCU in March 2009 is an example of what? |
Aggregate Data |
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Data that contains distinct, specified values. A natural order exists among the data values. |
Discrete Data |
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Pressure ulcer stages on a pt is an example of what? |
Discrete Data |
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Data that represents measurable quantities. Not restricted to certain specific values like discrete data. |
Continuous Data |
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Limited Data fields |
Structured Data |
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The medical record number of eight characters is an example of what |
Structure Data |
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"Free-text" data that is not limited by a set number of fields or spaces in a field. |
Unstructured Data |
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A physician's note is an example of what |
Unstructured Data |
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Data that can be added, subtracted, multiplied, or divided |
Numerical Data |
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Number of hours in a day is an example of what |
Numerical Data |
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Data that cannot be added, subtracted, multiplied, or divided |
Text Data |
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A street address is an example of what |
Text Data |
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Data that can be assigned via preset choices |
Categorical Data |
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Gender, race, and marital status are all examples of what? |
Categorical Data |
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Data that is assigned a specific numerical, alphabetical, or alphanumerical value to assist in data retrieval |
Coded Data |
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Patient medical record numbers, physician provider number, patient disposition codes, diagnoses and procedure codes are examples of what |
Coded Data |
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Data recorded as sound |
Audio Data |
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Echocardiogram, fetal heart monitor are examples of what |
Audio Data |
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Data recorded digitally |
Digital Data |
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Patient's history dictated into a digital dictation system is an example of what |
Digital Data |
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Images recorded digitally |
Digital Imaging |
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Captured heart tracings during cardiac catherizations, movement of opaque materials through the renal system during intravenous pyelography are examples of what |
Digital Imaging |
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Recording made on analog tape |
Analog |
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A voice recorded on a cassette tape is an example of what? |
Analog |
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Image that is mathematically rendered using lines and shapes |
Vector Graphic |
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Tracings such as EKGs or EEGs are examples of what? |
Vector Graphic |
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Image that is captured via a camera on a light-sensitive surface |
Photographic |
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Pictures taken during colonoscopies or arthroscopies are examples of what |
Photographic |
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Organized list of specific secondary data that facilitates reference to the data |
Index |
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Are indexes maintained manually or electronically? |
Both - but more commonly electronically. |
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What type of index contains the master patient, disease, procedure and physician index |
Facility-specific indexes |
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Index that contains patient-identifiable information such as the patient's name and address, date of birth, the dates the patient was hospitalized or outpatient encounters, the name of the attending physician, and the health record numer. |
Master Patient Index (MPI) |
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MPI |
Master Patient Index |
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What type of data source are MPIs |
Secondary |
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When are MPIs entered into the secondary data source |
At time of admission or pre-admission registration of the patient |
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A listing in diagnosis code number order for patients discharged from the facility |
Disease Index |
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What does the disease index include |
Patient health record number Diagnosis code(s) May include: Patient date of discharge Name of attending physician |
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Listing in a procedure code number order for pts having undergone a procedure at the facility |
Procedure (operation) Index |
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What does the procedure index include |
Procedure code number Patient's health record number May include: Date of Procedure Name of Surgeon |
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Listing of cases in order by physician name or identification number. |
Physician Index |
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What does the physician index include |
Patient's health record
Physician name or ID number May also include: Pt's date of discharge |
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What does the physician index enable? |
Enables one to retrieve information about a physician and the number of patients seen. |
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Type of registry that contains secondary data related to patients with a specific diagnosis, conditions, or procedure. |
Disease Register |
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What includes the methods used to identify the patients who have been seen and txed in the facility to be included in the registry |
Case Finding |
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Two different types of registries |
Facility-Based Population-Based |
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Registry base where data is collected from the hospital or clinic |
Facility-Based Registry
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Registry base where data could be collected form more than one hospital or other healthcare facility within the state or region |
Population-Based Registry |
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Number assigned in a registry when the case is first entered into registry consisting of the first digits of the yr the pt was seen at the facility and remaining digits sequentially throughout the yr. |
Accession Number |
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Should the registry attempt to follow up on ALL patients? |
Yes - on an annual basis |
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Which accreditations accredits Cancer Programs |
American College of Surgeons Commission on Cancer North American Association of Central Cancer Registries |
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Which accreditation certifies state population-based registries |
North American Association of Central Cancer Registries |
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What must a level 1 Trauma Center have? |
Trauma Registry |
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Which accreditation certifies trauma centers |
American College of Surgeons |
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What is the Birth Defects Registry age range |
Birth through first 5 yrs of life. |
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Do follow ups have to be done on trauma patients? |
Not required but can do so |
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Do follow ups have to be done on birth defect patients |
Not required but can do so |
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Who accredits the Birth Defects Registry? |
National Birth Defects Prevention Network |
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Does a diabetes registry have any accreditations? |
No |
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Does a diabetes registry perform follow ups on their patients? |
yes - to ensure the pt is seen by the physician at appropriate intervals |
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What type of databases are established for administration reasons rather than disease-oriented reasons? |
National and State Administrative Databases |
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What are the 4 types of National and State Administration Databases |
1. Medicare Provider Analysis and Review File (MEDPAR) 2. National Practicioner Data Bank (NPDB) 3. National health Care Surveys 4. Agency for Healthcare Research and Quality (AHRQ) |
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MEDPAR |
Medicare Provider Analysis and Review |
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NPDB |
National Practitioner Data Bank |
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AHRQ |
Agency for Healthcare Research and Quality |
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National and State database that collects data for all Medicare claims for acute care hospital and skilled nursing facilities. Used to research topics related to types of care and DRGs, but only for the Medicare population. |
MEDPAR Medicare Provider Analysis and Review File |
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National and State database of medical malpractice payments, sanctions taken by boards of medical examiners, and certain professional reviews taken by healthcare entities. This was mandated under the Health Care Quality Improvement Act of 1986. The law requires healthcare facilities to query the NPDB as part of the credentialing process. |
NPDB National Practitioner Data Bank |
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National and State database that contain major national public health surveys to assist public health agencies in surveying the health status of the population |
National Health Care Surveys |
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National and State database that reviews issues related to the efficiency and effectiveness of healthcare delivery systems disease protocols and guidelines for improved disease outcomes. |
AHRQ Agency for Health Care Research and Quality |
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What are two important methods for data collecting |
Abstracting and Monitoring |
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What is one of the most common processes of manual data collection |
Abstracting |
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Process in which the patient health record is reviewed for data that is gleaned from the health record for input into a database. Data may be inputted directly into the database or there might be an extra step involved in which data are abstracted into a form and then entered in the database from the form rather than directly from the health record. |
Abstracting |
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What are the 10 characteristics of data quality management that should be applied to the data collection process |
1. Accuracy 2. Accessibility 3. Comprehensiveness 4. Consistency 5. Currency 6. Definition 7. Granularity 8. Precision 9. Relevancy 10. Timeliness |
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Which data collection process consists of: Who is responsible for coordinating the data collection? How much time will it take to collect the data? Who will maintain the written data collection process/procedures? |
Accountability |
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Which data collection process consists of: What data is required? How are definitions for each element determined? Who will maintain the data dictionary? How reliable is the data source? |
Data Definition |
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Which data collection process consists of: What training is required for those collecting the data? What is the best data-collection tool? Can the data be collected so that it is available for analysis without further manipulation? |
Process Design/Standardizing Collection |
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Which data collection process consists of: What process will be used to monitor quality? Will the data be timely? Will feedback on data quality be provided? |
Quality Monitoring |
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ICD |
International Classification of Diseases |
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What systems are effective for going beyond simple recommendations to monitor patient data in real time and trigger alerts to dangerous situations? |
Clinical information |
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What are the challenges to representing data with controlled terminologies? |
Lack of availability of high quality terminologies. Resistance to the adoption of standards for representation. Inadequate mechanisms for capturing the data in coded form. |
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Is ICD fit for capturing data that is suitable for reuse? |
No |
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What are the 3 standard efforts that have begun producing terminologies that can support data reuse? |
Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) Logical Observation Identifiers Names and Codes (LOINC) RxNorm |
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What is SNOMED CT used for? |
Clinical Findings |
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What is LOINC used for? |
Laboratory Tests |
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What is RxNorm used for? |
Medications |
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SNOMED CT |
Systematized Nomenclature of Medicine Clinical Terms |
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LOINC |
Logical Observation Identifiers Names and Codes |
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Which terminologies address the issues of domain coverage, multiple hierarchies, and semantic representation that support tasks such as resuse |
SNOMED CT LOINC RxNorm |
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What have SNOMED CT, LOINC, and RxNorm been included in? |
Unified Medical Language Metathesaurus |
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True or False? Indexes contain more extensive data than Registries. |
False
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True or False? HIM Professionals recognize the importance of using standardized formats for collecting data so that quality data are collected. |
True |
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HIM professionals are involved in the process related to organizing the health record data in what kind of format? |
Usable |
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What is one of the most significant problems found in many documentation systems that is collected in the medical record |
Duplicate or Redundant Information |
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What can having duplicate information in a health record produce |
Confusion Diminishing credibility of the record |
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What are 2 ways of organizing data in the health record |
1. Eliminate duplicate documentation 2. Organize data into a useable format |
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Where can you find review of systems in a health record? |
In the history and physical report |
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Which component of the health record contains documentation regarding whether or not the patient has abnormal symptoms in the body systems surveyed. |
Review of Systems |
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What are types of diagnostic and tx service notes? |
Ancillary diagnostic and tx reports include: Laboratory Radiology Nutrition Respiratory therapy |
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Type of data that describes the methods utilized to diagnose the patient and provide relevant treatment. |
Clinical Data |
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Data that describes direct patient care |
Clinical Information |
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What are these an example of: Medical hx and physical Physician orders Progress Notes Medication administration recs Results of dx tests Summaries of therapeutic interventions Documentation among surg procedures Documentation of vital signs |
Clinical Data |
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What is data that includes supportive information incidental to patient care and relates to the "business" side of the provision of care. |
Administrative Data |
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What are these examples of: Patient demographics Patient registration info Consents Patient rights HIPAA Advance Directives Vital statistics (birth, death) Dx and Px coding summaries |
Administrative Data |
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What is referred to as how documentation or data is organized in both a paper-based and electronic environment. |
Format |
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Formatting options of paper-based medical record |
1. Source-oriented 2. Integrated 3. Problem-Oriented |
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What type of medical record are where forms are arranged according to the "source" such as administrative data, physician documentation, and nursing and clinical data. |
Source-oriented Medical Records |
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What is a system where all patient demographic information, consents, and administrative related documents are organized together, but hx and px, consults, operative rpts, etc are in a separate section |
Source oriented medical record |
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What are different sections in a source oriented medical record |
1. demographic, consents, etc. 2. consults, op reports, hx and px 3. nurse progress notes, MARS, graphics 4. radiology rpts, emgs |
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What is the advantage of a source oriented medical record |
Easy to track progress over time |
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Type of record documentation that refers to the practice of putting all forms in strict date order regardless of type or origin of form. |
Integrated |
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What is the advantage of an integrated medical record |
Easy to see what is occurring on a day-to-day basis but difficult to see progress. |
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SOAP |
Subjective, Objective, Assessment, Plan |
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POMR |
Problem-Oriented Medical Record |
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A method of organization and documentation where information is linked to a specific problem list that begins with the first patient admission and is updated with each piece of subsequent information. |
Problem-Oriented Medical Records |
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What is a key component of the POMR |
SOAP |
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What is SOAP used for? |
Writing progress notes |
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Which method of health records is an excellent educational and follow up tool that describes why drugs were prescribed or a particular test was ordered, etc. |
Problem-Oriented Medical Records |
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Which type of health record format enables the user to have great flexibility in determining how the data are organized |
Electronic format |
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What is the focus in regards to electronic health records |
Capabilities of the electronic health record |
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The functionalities of an electronic health record was identified in a report mandated by? |
U.S. Dpt of Health & Human Services |
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What are the functionalities of the electronic health record? |
Health information and data Result management Order management Decision support Electronic communication and connectivity Patient support Administrative processes and reporting Reporting and population health |
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What is the key to useful and reliable healthrecords |
Designing forms and templates |
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How do paper forms and electronic templates control information systems |
Demanding and standardizing action. Issuing instructions. Standardized vocab. Fixing responsibilities. Improve communication. |
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Who should be given a new charge of developing, reviewing, and controlling all enterprise wife information capture tools. |
Traditional Forms Committee |
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True or False? One of the benefits of using an electronic health record is that the format of the organization can be easily changed, such as from source to integrated organization. |
True |
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True or False? When designing paper-based forms, the normal font size must be limited to 12 points. |
False |
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When it comes to healthcare services today, what is one significant driving factor |
Data Integrity |
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How can data only be ensured |
Through a validation process |
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What are the tasks performed by RHITs in regards to validation processes |
Identify anomalies in data. Resolve risks and/or anomalies of data findings. Determine validation process for data mapping. |
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What refers to the discovery of events that do not conform to expected behaviors. |
Data anomalies |
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What are data anomalies a results of? |
Poorly planned databases |
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With data anomalies, where is the data usually stored that causes the result of poorly planned databases? |
All data is stored in one table |
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What are the discovery of events that do not conform to expected behaviors |
Outliers Exceptions Deviations |
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Poor quality data leads to what? |
Poor decision making |
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What are often a result of a poor plan that does not incorporate the characteristics of a data management plan? |
Data anomalies |
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Anomalies in data need to be reviewed for what? |
Potential missing characteristics |
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What is necessary between classifications and vocabularies to build a connection? |
Mapping |
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Mapping of what two characteristics should be needed to build a connection |
Classifications and Vocabularies |
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What is crucial in identifying the correct translation of data |
Mapping validation |
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