RHIA EXAM: INFORMATION GOVERNANCE (practice exam 1) 74 Questions with Answers,100% CORRECT

Document Content and Description Below

RHIA EXAM: INFORMATION GOVERNANCE (practice exam 1) 74 Questions with Answers Information Governance - CORRECT ANSWER Refers to the overall management of the availability, usability, integrity, a... nd security of company data Data Governance - CORRECT ANSWER Establishes the processes and responsibilities that ensure the quality and security of the data used across a business or organization A method of documenting a nurses' progress notes by recording only abnormal or unusual findings or deviations from the prescribed plan of care is called: - CORRECT ANSWER Charting by exception Charting by exception - CORRECT ANSWER a method of documenting only abnormal or unusual findings or deviations from the prescribed plan of care - the purpose of CBE is to reduce repetitive record keeping and documentation of normal events chief compliant - CORRECT ANSWER The nature and duration of the symptoms that caused the patient's illness and caused the patient to seek medical attention as stated in the patient's own words - reason for the visit data accuracy - CORRECT ANSWER An important aspect of data quality. It indicates whether data collected for an item are accurate. Data consistency - CORRECT ANSWER The extent to which the healthcare data are reliable and the same across all applications Data accessibility - CORRECT ANSWER Refers to a user's ability to access or retrieve data stored within a database. Data comprehensiveness - CORRECT ANSWER Means that all the required data elements are included in the health record. The record is complete. Mrs. Smith's admitting data indicates that her birth date is March 21, 1948. On the discharge summary, Mrs. Smith's birth date is recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record? - CORRECT ANSWER Data consistency Which of the following is an acceptable means of authentication a record entry? - CORRECT ANSWER The physician personally signs the entry electronically If an analyst is studying the wait times at a clinic and the only list of patients available is hard copy, which sampling technique is the easiest to use? - CORRECT ANSWER systemic sampling systemic sampling - CORRECT ANSWER The process of selecting a sample of subjects for a study by drawing every nth unit on a list - ex: every 5th patient in a waiting room cluster sampling - CORRECT ANSWER A probability sampling technique in which clusters of participants within the population of interest are selected at random, followed by data collection from all individuals in each cluster. stratified sampling - CORRECT ANSWER A type of probability sampling in which the population is divided into groups with a common attribute and a random sample is chosen within each group Resident Assessment Instrument (RAI) - CORRECT ANSWER A comprehensive tool that includes the minimum data set, resident assessment protocols, and guidelines for functional assessment of the resident resident assessment protocols (RAPs) - CORRECT ANSWER A summary of a long-term care resident's medical condition and care requirements utilization guidelines (UG) - CORRECT ANSWER specified in state operation manuals that direct when and how to use the RAI minimum data sets (MDS) - CORRECT ANSWER Part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. Provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Usually done by registered nurses. in a long-term care setting, these are problem-oriented frameworks for additional patient assessment based on problem identification items - CORRECT ANSWER resident assessment protocols (RAPs) entity-relationship diagram (ERD) - CORRECT ANSWER a technique for documenting the entities and relationships in a database environment object model - CORRECT ANSWER The end product of object-oriented analysis relational model - CORRECT ANSWER uses a two-dimensional table of rows and columns of data. Rows are records (also called tuples), and columns are fields (also referred to as attributes). unified medical language system (UMLS) - CORRECT ANSWER a program initiated by the National Library of Medicine to build an intelligent, automated system that can understand biomedical concepts, words, and expressions and their interrelationships; includes concepts and terms from many different source vocabularies what data model is most widely used to illustrate a relational database structure? - CORRECT ANSWER entity-relationship diagram Alex, an HIM analyst reviews the record of Patty, a patient in the facility, to ensure that all documents are complete and signatures are present. this is an example of a: - CORRECT ANSWER concurrent review concurrent review - CORRECT ANSWER review for medical necessity of tests and procedures ordered while a patient is still an inpatient in the hospital qualitative review - CORRECT ANSWER may involve checking documentation consistency, such as comparing a patient's pharmacy drug profile with the medication administration record. what type of information makes it easy for hospitals to compare and combine the contents of multiple patient health records - CORRECT ANSWER uniform data sets uniform data sets - CORRECT ANSWER a defined list of recommended data elements with uniform definitions that are relevant for a particular use time-out - CORRECT ANSWER The Joint Commission defines as "an immediate pause by the entire surgical team to confirm the correct patient, procedure, and site," serious event - CORRECT ANSWER Important medical events that may not be immediately life threatening or result in death or hospitalisation but may jeopardise the patient or require intervention to prevent one of the other outcomes sentinel event - CORRECT ANSWER an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof near miss - CORRECT ANSWER Error of commission or omission that could have harmed a patient, but harm did not occur as a result of chance Before Pam administers the medication, she scans both the medication and the newborns bracelet and learns that she has the incorrect medication for this patient. Pam does not administer that medication but goes back to the order and through the proper steps, administers the correct medication. Based on this scenario, which of the following occurred? - CORRECT ANSWER near miss which of the following materials are required elements in an emergency care record? - CORRECT ANSWER time and means of arrival, treatment rendered, instructions at discharge. in assessing the quality of care given to patients with diabetes mellitus, the quality team collects data regarding blood sugar levels on admission and on discharge. These data are called: - CORRECT ANSWER indicator indicator - CORRECT ANSWER a performance measure that enables healthcare organizations to monitor a process to determine wether it is meeting process requirements unique identifier - CORRECT ANSWER Way of uniquely identifying each record in the database case management - CORRECT ANSWER optimizes self-care capabilities of individuals and families and the capacity of systems and communities to coordinate and provide services outcomes and assessment information set (OASIS) - CORRECT ANSWER a group of standard data elements designed to enable systematic comparative measurement of home health care patient outcomes at two points in time in adult skilled Medicare and Medicaid, non-maternity home health care patients. which of the following is used by a long term care facility to gather information about specific health status factors and includes information about specific risk factors in the residents care? - CORRECT ANSWER minimum data set dr collins admitted mr smith to university hospital. BCBS insurance will pay mr smith's hospital bill. Upon discharge from the hospital, who owns the health record of mr smith? - CORRECT ANSWER university hospital, the healthcare provider integrated format - CORRECT ANSWER Chronological order (MR in which info is organized in a strict chronological order) chronological - CORRECT ANSWER Arranged in order of time of occurrence source-oriented - CORRECT ANSWER organized by the entity that supplied the data Ex: all lab reports are in the lab report tab, all x-ray reports are in the radiology tab - CORRECT ANSWER source-oriented comparative performance data - CORRECT ANSWER When healthcare organizations evaluate their Joint Commission core measure data with similar organization master patient index - CORRECT ANSWER the primary index used for HIM recordkeeping, which includes a unique record for each patient within a healthcare organization Jane emailed her physician to express concern about a lab result. Her physician responded and explained the result as well as offered various treatment options. How should this email correspondence be handled? - CORRECT ANSWER Since this email correspondence relates to communication between a physician and a patient and includes PHI, the facility should include the email in the patients medical record The insured party's member identification number is an example of this type of data: - CORRECT ANSWER financial data financial data - CORRECT ANSWER health care providers use this data to complete claims forms that will be submitted to third-party payers demographic data - CORRECT ANSWER information collected at the time of registration such as age, gender, race and ethnicity; becomes a part of the patient's medical record in a relational database, which of the following is an example of a many-to-many relationship? - CORRECT ANSWER patients to consulting physicians - patients can see many physicians - physicians can see many different patients borrowing records entries from another source as well as representing or displaying past documentation as current are examples of a potential breach of: - CORRECT ANSWER authorship integrity the process by which a person or entity who authored an EHR entry or document seeks to validate that they are responsible for the data within is called: - CORRECT ANSWER authentication Anywhere Hospital has mandated that the social security number will be displayed in the XXX-XX-XXXX format for their patients. This is an example of the use of a: - CORRECT ANSWER mask decision making and authority over data-related matters is known as: - CORRECT ANSWER data governance data management - CORRECT ANSWER A process that focuses on data collection, storage, and retrieval. Common data management functions include addition, deletion, modification, and listing. data administration - CORRECT ANSWER Responsible for specific policies and procedures through which data can be managed as a resource data modeling - CORRECT ANSWER The process of creating a specific data model for a determined problem domain. sue is updating the data dictionary for her organization. in this data dictionary, the data element name is considered which of the following? - CORRECT ANSWER metadata metadata - CORRECT ANSWER data that describes other data ex: data type, data element name, field length structured data - CORRECT ANSWER Data that are organized and easily retrievable and interpreted by traditional databases and data models unstructured data - CORRECT ANSWER data that do not have a predefined data model or are not stored in a traditional database structure free-text data - CORRECT ANSWER data that are narrative in nature; unstructured narrative data the data elements in a patients automated laboratory result are examples of: - CORRECT ANSWER structured data Data that are collected on large populations of individuals and stored in a database without identifying any particular patient individually are referred to as: - CORRECT ANSWER aggregate data aggregate data - CORRECT ANSWER Any process whereby data is gathered and expressed in a summary form accession data - CORRECT ANSWER a unique number that is used to identify a patients when a case is first entered in the registry notes written by physicians and other practitioners as well as dictated and transcribed reports are examples of: - CORRECT ANSWER unstructured clinical data unstructured clinical data - CORRECT ANSWER lacks the organization and precision of structured data ex; physicians notes, standardized data - CORRECT ANSWER the process of converting data to a common format to enable users to process and analyze it. according to the Joint Commission accreditation standards, which document must be placed in the patient's health records before a surgical procedure can be performed? - CORRECT ANSWER report of history and physical examination [Show More]

Last updated: 7 months ago

Preview 1 out of 8 pages