RHIT Prep Domain 1: Data Analysis and Management Exam, Exams of Advanced Data Analysis

Download RHIT Prep Domain 1: Data Analysis and Management Exam and more Exams Advanced Data Analysis in PDF only on Docsity! RHIT Prep Domain 1: Data Analysis and Management EXAM LATEST UPDATED WITH CORRECTLY ANSWERED QUESTIONS. 1. data dictionary - Correct answer A critical early step in designing an EHR is to develop a(n) _____ in which the characteristics of each data element are defined. 2. data sets - Correct answer One hospital discharge abstract systems were developed and their ability to provide comparative data to hospitals was established, it became necessary to develop: 3. data sets - Correct answer Two purposes are served by _____: to identify data elements to be collected about each pt & provide uniform data definitions. 4. UHDDS: Uniform Hospital Discharge Data Set - Correct answer The first resource that an HIT should consult when designing a data collection form to collect data on pts in an acute-care hospital is: 5. UHDDS: Uniform Hospital Discharge Data Set - Correct answer The purpose of the _____ is to list and define a set of common, uniform data elements. The data elements are collected from the health records of every hospital inpt and later abstracted from the health record and included in national databases. 6. Data set - Correct answer A _____ is a list of recommended data elements with uniform definitions that are relevant for a particular use. the contents of _____ vary by their purpose & are not meant to limit the number of data elements that can be collected. 7. quantitative - Correct answer When deficiencies in the health record, such as reports that need to be dictated or signed by a physician or other health professional, are identified through ____ analysis, the record is filed in a specially designated area of the HIM department, frequently called the incomplete file room. 8. Incomplete record - Correct answer In a paper-based system, the completion of the chart is monitored in a special area of the HIM department called the _____ file room. 9. MPI: Master Patient Index - Correct answer a list or database created and maintained by a healthcare facility to record the name and identification number of every pt who has ever been admitted or treated in the facility. While not listed as one of the core elements of an _____, AHIMA recommends the use of a Unique Patient Identifier to be included in the core data elements of the _____. 10.Unit number - Correct answer filing system in which the pt receives a unique health record number at the time of the first encounter. For all subsequent encounters for a particular pt, the health record number that was assigned for the first encounter is used 11.alphabetic filing system - Correct answer The following are disadvantages of _____: 12.Does not ensure a unique identifier. 13.Does not expand evenly. 14.Time consuming to purge or clean out files for inactive storage. 15.alphabetic filing system - Correct answer This system is usually satisfactory for a very small volume of records like that of a small physician practice. 16. requisition - Correct answer a _____ is a request from a clinical or other area in the organization to charge out a specific health record. It may be in paper or electronic form. 17.elements of a requisition - Correct answer Usually includes the pt's name, health record number, date of the request, date and time needed, name of the requester, and location for delivery. 18.case mix index - Correct answer The average relative weight of all cases treated at a given facility or by a given physician which reflects the resource intensity or clinical severity of a specific group in relation to the other groups in the classification system: Sum of the # of cases in each DRG X weight for that DRG / Total Cases 19.MS-DRG triples, pairs, and singles - Correct answer In analyzing the reason for changes in hospital's Medicare case-mix index over time, the analyst should start with which level of detail? 20.outguide - Correct answer The _____ is the most common type of tracking system used to track paper-based health records. It is usually made of strong colored vinyl with two plastic pockets and is the size of a regular record folder and is place in the record location when the record is removed from the file. 21.confidentiality, integrity, and availability - Correct answer The goals of the HIPAA security rule are to ensure the _____, _____, and _____ of the ePHI. 22. Integrity - Correct answer _____ is ensuring that data are not altered either during transmission across a network or during storage. 45.Data, Information - Correct answer _____ represents basic facts, while _____ represents meaning. 46.Structure and content - Correct answer Information standards that provide clear descriptors of data elements to be included in computer-based pt record systems are called _____ standards. 47.data currency / timeliness - Correct answer _____ means that healthcare data should be up-to-date and recorded at or near the time of the event or observation. 48.data consistency - Correct answer _____ means that the data is reliable. Reliable data do not change no matter how many times or in how many ways they are stored, processed or displayed. 49.scatter diagram - Correct answer A _____ is used to plot the points for two continuous variables that may be related to each other in some way. Ex: Age & blood pressure; one would be plotted on the x-axis and the other on the y-axis 50.Data quality model - Correct answer _____ applies the following quality characteristics: data accuracy, data accessibility, data comprehensiveness, data consistency, data currency, data definition, data granularity, data precision, data relevancy, and data timeliness. 51.data granularity - Correct answer _____ requires that the attributes and values of data be defined at the correct level of detail for the intended use of the data. Ex: numerical measurement carried out to the appropriate decimal place 52.Primary Purpose - Correct answer Pt care delivery, pt care management, pt care support processes, financial & other administrative processes and pt self management are all ____(s) of the health record. 53.Data comprehensiveness - Correct answer _____ means that all the required data elements are included in the health record (the record is complete). 54.Data accessibility - Correct answer _____ means that the data are easily obtainable. 55.Patient registration - Correct answer _____ is the unit/department in which the health record number is typically assigned. 56.operative - Correct answer The _____ report describes the surgical procedures performed on the pt. 57.Medical Laboratory - Correct answer The _____ report includes tests performed on blood, urine, and other samples from the pt. 58.Discharge summary - Correct answer The _____ is a concise account of the pt's illness, course of Tx, response to Tx, and condition at the time the pt is dicharged from the hospital. Also includes follow-up care instructions & provides an overview of the entire medical encounter. It is the responsibility of, and must be signed by, the attending physician. 59.Nurses - Correct answer _____ maintain chronological records of the pt's vital signs & separate logs that show what medications were ordered and when they were administered. 60.Clinical - Correct answer _____ data document the pt's medical condition, Dx, and procedures performed as well aas the healthcare Tx provided. 61.Administrative - Correct answer _____ data include demographic and financial information as well as various consents and authorizations related to the provision of care and the handling of confidential pt info. 62.ECG Report - Correct answer The following is documented in an acute-care record: "Atrial fibrillation with rapid ventricular response, left axis deviation, left bundle branch block." In what type of report would this documentation appear? 63.Social Services Note - Correct answer The following is documented in an acute- care record: "Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CPS re: referral. Case manager to meet w/ pt & family." In what type of documentation would this appear? 64.Emergency - Correct answer Patient's instructions at discharge, time & means of pt's arrival, care administered before arrival at the facility & clinical observations are all likely to be included in the pt's health record for an _____ visit, though the pt's complete medical history would not. 65.problem-oriented - Correct answer The _____ health record is better suited to serve the pt & the end user of the pt info. The key characteristic of this format is an itemized list of the pt's past & present social, psychological, & medical problems. Each problem is indexed with a unique number & are organized in numerical order. Consists of 4 components: database, problem list, initial plan & progress notes. 66.numeric - Correct answer In a problem-oriented health record, problem are organized in ____ order 67.source-oriented record - Correct answer A traditional patient record format known as the _____ maintains reports according to source of documentation. Ex: documentation generated by nursing staff would be located in the nursing section of the record. 68.Source-Oriented Record - Correct answer Advantages: Files same source docs together; Easy to locate information from same source. 69.Disadvantages: Difficult to follow one diagnosis; Create many sections in record; Filing reports is time consuming 70.Problem-Oriented Record - Correct answer Advantages: Links all documentation to a specific problem; Facilitates patient treatment and education. 71.Disadvantages: Requires training; Filing of reports is time consuming; Data associated w/ more than 1 problem must be documented several times. 72. Integrated Record - Correct answer Advantages: Provides high degree of organization; Easy to use; All info on an episode of care is filed together; Less time-consuming to file reports. 73.Disadvantages: Difficult to compare & retrieve info from same discipline 74. Integrated Record - Correct answer The _____ format usually arranges reports in strict chronological order. This format allows for observation of how the pt is progressing & is responding to treatment. 75.consultation report - Correct answer The _____ documents the clinical opinion of a physician other than the primary or attending physician. 76.primary source - Correct answer records that document pt care provided by healthcare professionals and include original pt record, X-rays, scans, EKGs & other documents of clinical findings. 77.secondary sources - Correct answer pt info that contains data abstracted (selected) from the original pt record, X-rays, scans, EKGs & other documents of clinical findings such as indexes & registers, committee minutes, & incident reports. Sometimes referred to as "aggregate" data. 78.secondary - Correct answer Examples of _____ purposes of the health record are support for research, to serve as evidence in litigation, to allocate resources, and to plan market strategy. 79.primary - Correct answer Patient care management refers to all the activities related to managing the healthcare services provided to patients and is a _____ purpose of the health record. 80.ASTM: American Society for Testing and Materials - Correct answer _____ is an international standards organization that develops and publishes voluntary consensus technical standards for a wide range of materials, products, systems, and services. The _____ Technical Committee on Health Informatics E31 is charged with the responsibility for developing standards related to the EHR.