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14 Cards in this Set

  • Front
  • Back

A health record technician has been asked to review the discharge patient abstracting module of a proposed new EHR. Which of the following data sets would the technician consult to ensure the system collects all federally required discharge data elements for Medicare and Medicaid inpatients in an acute-care hospital? (pg 2)





ANSWER (pg. 170): D. The Uniform Hospital and Discharge Data Set (UHDDS) data characteristics include patient-specific items on every inpatient (Sayles 2013, 146-148)

The RHIT supervisor for the filing and retrieval section of Community Clinic is developing a staffing schedule for the year. The clinic is open 260 days per year and has an average of 500 clinic visits per day. The standard for filing records is 50 records per hour. The standard for retrieval of records is 40 records per hour. Given these standards, how many filing hours will be required daily to retrieve and file records for each clinic day? (pg 2)

A. 10 hours per day

B. 11.11 hours per day

C. 12.5 hours per day

D. 22.5 hours per day

ANSWER (pg 170):

D. Timeliness of the storage and retrieval processes processes should be monitored. In this situation, each clinic visit represents a patient record that will need to be retrieved (or pulled) and stored (filed back). The calculation is: (500/50) + (500/40) = 22.5 hours per day (Sayles 2013, 358)

3. Standardizing medical terminology to avoid differences in naming various health conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallux valgus) is one purpose of: (pg 2)

A. Content and structure standards

B. Security standards

C. Transactions standards

D. Vocabulary standards

ANSWER (page 170): D. Vocabulary Standards provide consistent descriptions of medical terms for an individual's condition in the health record (Sayles 2013, 41).

4. Patient care managers use the data documented in the health record to (pg 2):

A. Determine the extent and effects of occupational hazards.

B. Evaluate patterns and trends of patient care.

C. Generate patient bills and third-party payer claims for reimbursement

D. Provide direct patient care

ANSWER (pg 170): B. Patient care managers are responsible for the overall evaluation of services rendered for their particular area of responsibility. To identify patterns and trends, they take details from individual health records and put all the information together in one place. On the basis of these aggregate data, the managers recommend changes to patient care processes, equipment, and services.

The active storage area for health records at Community Hospital is almost filled. To create more space in the storage area, which of the following should be done? (pg 2)

A. Discard the oldest records

B. Purge oldest records to another location

C. Remove nursing notes from the oldest records

D. Remove the file folders from all the records

ANSWER (pg 170): B. When space is not sufficient to house health records required for patient care and other purposes, older health records are purged or removed from the file area. Generally, files that have been inactive for a certain period of time (for example, three years since the patient's last visit) are removed from the active filing area (Sayles 2013, 336-337).

6. As part of the initiative to improve data integrity, the Data Quality Committee conducted an inventory of all the hospital's databases. The review showed that more than 70 percent of the identified databases did not have data dictionaries. Given this data, what should be the committee's first action? (pg 3)

A. Disregard the data

B. Establish a data dictionary policy with associated standards

C. Establish an in-service training program ton data dictionary use

D. Distribute a memorandum to all department heads on the value of a data dictionary

ANSWER (page 170): B. The results of the inventory indicate a significant problem and should not be ignored. Before in-service training or memos can be developed, the organization's formal position on data dictionaries must be established through development of a policy and associated standards (Sayles 2013, 1083).

(What is a data dictionary? a set of information describing the contents, format, and structure of a database and the relationship between its elements, used to control access to and manipulation of the database.)

7. Community Hospital has more than 100 clinical databases. The Data Quality Committee is studying the comparability among the databases. The data elements and data definitions are cataloged for each database. What would be the next logical step to determine the degree of data comparability among the databases? (pg 3)

A. Identify the operating system for each database to determine if they are similar to each other

B. Determine the volume and type of data stored within eafeloped

C. Identify the network capability of each of the databases so that data an be exchanged

D. Select a representative set of data elements and track these across the databases to identify consistencies and differences

ANSWER (pg 170): D. Careful attention must be given to ensure that data stored in a database have data quality characteristics including accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, and timeliness (Sayles 2013, 885)

8. Data elements collected on large populations of individuals and stored in databases are referred to as:

A. Statistics

B. Information

C. Aggregate data

D. Standard

ANSWER (pg 170) C. Data about patients can be extracted from individual health records and combined as aggregate data. Aggregate data are used to develop information about groups of patients. For example, data about all patients who suffered an acute myocardial infarction during a specific time period could be collected in a database. (Sayles 2013, 141)

9. At admission, Mrs. Smith's date of birth is recorded as 3/25/1948. An audit of the EHR discovers that the numbers in the date of birth are transposed in reports. This situation reflects a problem in:

A. Data comprehensiveness

B. Data consistency

C. Data Currency

D. Data granularity

ANSWER (pg 170): B. Data consistency means that the data are reliable. Reliable data do not change no matter how many times or in how many ways they are stored, processed, or displayed. For example, the clinical history for a male patient would not likely include a hysterectomy as a past surgical procedure (Sayles 2013, 52).

10. A health data analyst has been asked to compile a listing of daily blood pressure readings for patients with a diagnosis of hypertension who were treated on the medical unit within a two-week period. What clinical report would be the best source to gather this information? (3)

A. Admission record

B. Initial nursing assessment record

C. Physician progress notes

D. Vital signs records

ANSWER (pg 170): D. The vital signs record is comprised of blood pressure readings , temperature, respiration, and pulse, making it the best source to gather this type of information. (Sayles 2013, 80)

11. Which of the following is a key characteristic of the problem-oriented health record? (4)

A. Allows all providers to document in the health record

B. Uses laboratory reports and other diagnostic tools to determine health problems

C. Provides electronic documentation in the health record

D. Uses an itemized list of the patient's past and present health problems

ANSWER (170): D. The problem-oriented health record is better suited to serve the patient and the end user of the patient's information. The key characteristic of this format is an itemized list of the patient's past and present social, psychological, and health problems. Each problems is indexed with a unique number. (Sayles 2013, 126)
12. Based on the payment percentages provided in this table, which payer contributes most to the hospital's overall payments? (4)

B. Commercial
C. Medicare

12. Based on the payment percentages provided in this table, which payer contributes most to the hospital's overall payments? (4)


B. Commercial

C. Medicare


ANSWER (pg 171): IN the "payments" column, Medicare has the highest payment percentage (42 percent) of any of the payers; therefore, Medicare contributes more to the hospital's overall payments (Sayles 2013, 520).

13. Which of the following is true regarding the reporting of communicable diseases? (pg 4)

A. They must be reported by the patient to the health department.

B. The diseases to be reported are established by state law.

C. The diseases to be reported are established by HIPAA.

D. They are never reported because it would violate the patient's privacy.

ANSWER (171): B. All states have a health department with a division that is required to track and record communicable diseases. When a patient is diagnosed with one of the diseases from the health department's communicable disease list, the facility must notify the state public health department. (Shaw and Carter 2015, 189)