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196 Cards in this Set

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What is the crucial first step for effective management of data and it is also performed continuously as needed.


What happens when planning is not performed?

It is difficult to make effective decisions and determine the success of a project or program.

Identification of what in data management plan is crucial?

Goals and objectives

Budget and time constraints


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.

Critical tasks performed by RHITs

Participate in the data management plan

Develop data management plan

Maintain data dictionaries

What does participating in the data management plan include:

Determining data elements.

Assemble components.

Set time-frames.

What are the foundation of the EHR

Data elements

What is needed to maintain high-quality data that leads to high-quality information and decisions

Data management plans

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.

Recommended or required summary of data elements which apply to a particular activity.

Data Set

Example of data set

Address which consists of:


Street or post office number



Zip Code


Uniform Hospital Data Discharge Set

Can one data set be apart of another?


What is the UHDDS

Data Set

Examples of different data sets










There are 9


Data Elements for Emergency Dpt Systems

Included 156 data elements for hospital emergency rooms.


Essential Medical Data Set

Compliments DEEDS incorporating medical history elements into ER data collection.


Healthcare Effectiveness Data and Information Set

Tool used by health plans in American which contains performance measures on important dimensions of car and service.


Inpatient Rehabilitation Facility - Patient Assessment Instrument


Minimum Data Set

For long-term care and Resident Assessment Protocols


National Electronic Disease Surveillance System


National Hospital Ambulatory Medical Care Survey


Outcome and Assessment Information Set

used in Home health


Uniform Ambulatory Care Data Set

What is an accepted way of doing a task or a guide for expected performance?


What are standards that have been set to ensure uniformity of data exchange?

Accepted formats

What are the different forms of patient data


Digital Image

Electrical tracings

Sound recordings

What is a tool organizations can use to help ensure data accuracy?

Data Dictionary

What is a dynamic document that is evaluated as data needs change or grow.

Data Dictionary

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

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

What is the purpose and function of the health record?

Review of systems

Promotes data integrity by supporting the adoption and use of consistent data elements and terminology within health IT systems

Data Dictionary

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.


Is the purpose of a health record to educate healthcare professionals primary or secondary purpose?


What involves uniform standardization of practices, policies, and procedures that results in reliable and consistent data.

Health Data Collection

What are examples of abstract information found in health records



Physician deficiencies

What does collecting information from a variety of sources allow HIM professionals to do?

Validate the accuracy of information

What promotes inter-operability and automates data sharing?

Metadata registry

aka data dictionary

What is data derived directly from a source such as data in the health record.

Primary data

What is data taken from the primary source and entered into registries and databases?

Secondary data

What is another name for aggregate data

Collective data

What is another name for discrete data

Separate or Individual data

Structure data

Limited character fields

Unstructured data

Free Text

Different methods data can be stored





Different types of data





Vector graphic


What is another name for vector graphic data


What is data and an example

Raw facts

Ex. Patient height and weight

What is information

Processed data

What type of data is a patients weight and height


Data derived from a secondary sourced; based on analysis of data derived from an aggregate of primary sources

Primary Data

A patients BMI is an example of what?



Because it is derived from the patient's height and weight.

What is processed data?


A patient's age is an example of what?

Primary Data

Data that is derived from a secondary source; based on analysis of data derived from an aggregate of primary sources

Secondary Data

The average age when adult onset diabetes is first diagnosed in women is an example of what?

Secondary Data

Collective Data

Aggregate Data

The total number of pts admitted to the CCU in March 2009 is an example of what?

Aggregate Data

Data that contains distinct, specified values. A natural order exists among the data values.

Discrete Data

Pressure ulcer stages on a pt is an example of what?

Discrete Data

Data that represents measurable quantities. Not restricted to certain specific values like discrete data.

Continuous Data

Limited Data fields

Structured Data

The medical record number of eight characters is an example of what

Structure Data

"Free-text" data that is not limited by a set number of fields or spaces in a field.

Unstructured Data

A physician's note is an example of what

Unstructured Data

Data that can be added, subtracted, multiplied, or divided

Numerical Data

Number of hours in a day is an example of what

Numerical Data

Data that cannot be added, subtracted, multiplied, or divided

Text Data

A street address is an example of what

Text Data

Data that can be assigned via preset choices

Categorical Data

Gender, race, and marital status are all examples of what?

Categorical Data

Data that is assigned a specific numerical, alphabetical, or alphanumerical value to assist in data retrieval

Coded Data

Patient medical record numbers, physician provider number, patient disposition codes, diagnoses and procedure codes are examples of what

Coded Data

Data recorded as sound

Audio Data

Echocardiogram, fetal heart monitor are examples of what

Audio Data

Data recorded digitally

Digital Data

Patient's history dictated into a digital dictation system is an example of what

Digital Data

Images recorded digitally

Digital Imaging

Captured heart tracings during cardiac catherizations, movement of opaque materials through the renal system during intravenous pyelography are examples of what

Digital Imaging

Recording made on analog tape


A voice recorded on a cassette tape is an example of what?


Image that is mathematically rendered using lines and shapes

Vector Graphic

Tracings such as EKGs or EEGs are examples of what?

Vector Graphic

Image that is captured via a camera on a light-sensitive surface


Pictures taken during colonoscopies or arthroscopies are examples of what


Organized list of specific secondary data that facilitates reference to the data


Are indexes maintained manually or electronically?

Both - but more commonly electronically.

What type of index contains the master patient, disease, procedure and physician index

Facility-specific indexes

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)


Master Patient Index

What type of data source are MPIs


When are MPIs entered into the secondary data source

At time of admission or pre-admission registration of the patient

A listing in diagnosis code number order for patients discharged from the facility

Disease Index

What does the disease index include

Patient health record number

Diagnosis code(s)

May include:

Patient date of discharge

Name of attending physician

Listing in a procedure code number order for pts having undergone a procedure at the facility

Procedure (operation) Index

What does the procedure index include

Procedure code number

Patient's health record number

May include:

Date of Procedure

Name of Surgeon

Listing of cases in order by physician name or identification number.

Physician Index

What does the physician index include

Patient's health record

Physician name or ID number

May also include:

Pt's date of discharge

What does the physician index enable?

Enables one to retrieve information about a physician and the number of patients seen.

Type of registry that contains secondary data related to patients with a specific diagnosis, conditions, or procedure.

Disease Register

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

Two different types of registries



Registry base where data is collected from the hospital or clinic

Facility-Based Registry

Registry base where data could be collected form more than one hospital or other healthcare facility within the state or region

Population-Based Registry

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

Should the registry attempt to follow up on ALL patients?

Yes - on an annual basis

Which accreditations accredits Cancer Programs

American College of Surgeons Commission on Cancer

North American Association of Central Cancer Registries

Which accreditation certifies state population-based registries

North American Association of Central Cancer Registries

What must a level 1 Trauma Center have?

Trauma Registry

Which accreditation certifies trauma centers

American College of Surgeons

What is the Birth Defects Registry age range

Birth through first 5 yrs of life.

Do follow ups have to be done on trauma patients?

Not required but can do so

Do follow ups have to be done on birth defect patients

Not required but can do so

Who accredits the Birth Defects Registry?

National Birth Defects Prevention Network

Does a diabetes registry have any accreditations?


Does a diabetes registry perform follow ups on their patients?

yes - to ensure the pt is seen by the physician at appropriate intervals

What type of databases are established for administration reasons rather than disease-oriented reasons?

National and State Administrative Databases

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)


Medicare Provider Analysis and Review


National Practitioner Data Bank


Agency for Healthcare Research and Quality

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.


Medicare Provider Analysis and Review File

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.


National Practitioner Data Bank

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

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.


Agency for Health Care Research and Quality

What are two important methods for data collecting

Abstracting and Monitoring

What is one of the most common processes of manual data collection


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.


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

Which data collection process consists of:

Who is responsible for coordinating the data collection?
Who is responsible for monitoring the quality of data?

How much time will it take to collect the data?

Who will maintain the written data collection process/procedures?


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

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

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


International Classification of Diseases

What systems are effective for going beyond simple recommendations to monitor patient data in real time and trigger alerts to dangerous situations?

Clinical information

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.

Is ICD fit for capturing data that is suitable for reuse?


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)


What is SNOMED CT used for?

Clinical Findings

What is LOINC used for?

Laboratory Tests

What is RxNorm used for?



Systematized Nomenclature of Medicine Clinical Terms


Logical Observation Identifiers Names and Codes

Which terminologies address the issues of domain coverage, multiple hierarchies, and semantic representation that support tasks such as resuse




What have SNOMED CT, LOINC, and RxNorm been included in?

Unified Medical Language Metathesaurus

True or False?

Indexes contain more extensive data than Registries.


True or False?

HIM Professionals recognize the importance of using standardized formats for collecting data so that quality data are collected.


HIM professionals are involved in the process related to organizing the health record data in what kind of format?


What is one of the most significant problems found in many documentation systems that is collected in the medical record

Duplicate or Redundant Information

What can having duplicate information in a health record produce


Diminishing credibility of the record

What are 2 ways of organizing data in the health record

1. Eliminate duplicate documentation

2. Organize data into a useable format

Where can you find review of systems in a health record?

In the history and physical report

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

What are types of diagnostic and tx service notes?

Ancillary diagnostic and tx reports include:




Respiratory therapy

Type of data that describes the methods utilized to diagnose the patient and provide relevant treatment.

Clinical Data

Data that describes direct patient care

Clinical Information

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

What is data that includes supportive information incidental to patient care and relates to the "business" side of the provision of care.

Administrative Data

What are these examples of:

Patient demographics

Patient registration info


Patient rights


Advance Directives

Vital statistics (birth, death)

Dx and Px coding summaries

Administrative Data

What is referred to as how documentation or data is organized in both a paper-based and electronic environment.


Formatting options of paper-based medical record

1. Source-oriented

2. Integrated

3. Problem-Oriented

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

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

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

What is the advantage of a source oriented medical record

Easy to track progress over time

Type of record documentation that refers to the practice of putting all forms in strict date order regardless of type or origin of form.


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.


Subjective, Objective, Assessment, Plan


Problem-Oriented Medical Record

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

What is a key component of the POMR


What is SOAP used for?

Writing progress notes

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

Which type of health record format enables the user to have great flexibility in determining how the data are organized

Electronic format

What is the focus in regards to electronic health records

Capabilities of the electronic health record

The functionalities of an electronic health record was identified in a report mandated by?

U.S. Dpt of Health & Human Services

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

What is the key to useful and reliable healthrecords

Designing forms and templates

How do paper forms and electronic templates control information systems

Demanding and standardizing action.

Issuing instructions.

Standardized vocab.

Fixing responsibilities.

Improve communication.

Who should be given a new charge of developing, reviewing, and controlling all enterprise wife information capture tools.

Traditional Forms Committee

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 or False?

When designing paper-based forms, the normal font size must be limited to 12 points.


When it comes to healthcare services today, what is one significant driving factor

Data Integrity

How can data only be ensured

Through a validation process

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.

What refers to the discovery of events that do not conform to expected behaviors.

Data anomalies

What are data anomalies a results of?

Poorly planned databases

With data anomalies, where is the data usually stored that causes the result of poorly planned databases?

All data is stored in one table

What are the discovery of events that do not conform to expected behaviors




Poor quality data leads to what?

Poor decision making

What are often a result of a poor plan that does not incorporate the characteristics of a data management plan?

Data anomalies

Anomalies in data need to be reviewed for what?

Potential missing characteristics

What is necessary between classifications and vocabularies to build a connection?


Mapping of what two characteristics should be needed to build a connection

Classifications and Vocabularies

What is crucial in identifying the correct translation of data

Mapping validation