A criticle early step in designing an EHR is to develop a(an) _________in which the characteristics of each data element are defined.
What is data dictionary (Johns 2011, pg 199)
100
In a paper-based system, the completion of the chart is monitored in a special area of the HIM department called the ____________file.
What is an Incomplete Record? (Johns 2011, pg 411-412)
100
In analyzing the reason for changes in hospital's Medicare case-mix index over time, the anyalyst should start with what level of detail?
What is MS-DRG triples, pairs, and singles? (Schraffenberger and Kuehn 2011, pg 483)
100
Incorporating a workflow function in an electronic information system would help support:
What is Task that need to be performed in a specific sequence. (Johns 2011, pg 208)
100
The attending physician is responsible for which type of acute-care documentation?
What is Discharge summary, progress notes. (Johns 2011, pg 78)
200
Once hospital discharge abstract systems were developed and their ability to provide comparative data to hospitals was established, it became necessary to develop:
What is Data Sets? (Johns 2011, pg 197)
200
The MPI is neccessary to physicaly locate helath records within the paper-based storage system for all types of filing systems, except:
What is Alphanumerical? (Johns 2011, page 382)
200
In long-term care, the residents's care jplan ius based on data collected in the ____________.
What is MDS? (Johns 2011, pg 208)
200
Information standards that provide clear descriptiors of data elements to be included in computer-based patient record systems are called____________standards.
What is Structure and content. (Johns 2011, pg 225)
200
Identify where the following information would be found in the acute-care medical record. "CBC: WBC 12.0, RBC 4.65, HGB 14.8, HCT 43.3, MCV 93."
What is Medical Laboratory Report. (Johns 2011, pg 70)
300
In healthcare, data sets serve two purposes. The first is to identify data elements to be collected about each patient. The second is to:
What is Provide uniform data definitions? (Johns 2011, pg 201)
300
The data set designated to organize data for public release about the outcomes of care is:
What is HEDIS? (Johns 2011, 210)
300
What is the mean for the following frequency distribution: 10, 15, 20, 25,?
What is 19. (Johns 2011, 529)
300
A nurse is responsible for the following types of acute-care documentation.
What is Medication record, nursing progress notes. (Johns 2011, pg 68)
400
A health information technician is responsible for designing a data collection form to collect data on patients in an acute-care hospital. The first resource that should use is:
What is UHDDS? (Johns 2011, pg 202)
400
What is the difference between data and information?
What is Data represent basic facts, while information represents meanings. (Johns 2011, 28-29)
400
Suppose 5 patients stayed in the hospital for a total of 27 days. What term would be used to describe the result of the calculation 27 divided by 5.
What is Average length of stay. (Johns 2011, 553)
400
In a problem-oriented health record, problems are organized in what order?
What is Numerical order. (Johns 2011, 114)
500
What is the term that is used to mean ensuring that data are not altered during transmission across a network or during storage.
What is Integrity? (Sayles and Trawick 2010, pg 300)
500
What department unit is the health record number typically assigned?
What is Patient registration. (Johns 2011, 386-387)
500
Two clerks are abstracting data for the same case for a registry. When their work is checked, discrepencies are found. What a data quality components is missing.
What is Relaibility. (Johns 2011, 509)
500
What term is used for the number of inpatients present at tany one time in a healthcare facility?
What is Census. (Johns 2011, pg 547)
500
The following is documented in a acute care record: "HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head truama. CHEST: Good bilateral chest sounds." In what document would this documentation appear?
What is Physical Examination. (Johns 2011, 63, 65)