Deck 2: Collecting and Storing Health Care Data

Question 1

Organized data that have been collected about a patient or a group of patients is called:

A) the health record.
B) epidemiology.
C) health data.
D) health information.

Answer 1

health information.

Question 2

Data is a plural term. What is the singular form of the word data?

A) datum
B) datus
C) dato
D) datae

Answer 2

datum

Question 3

You create a list of all the cases of the flu seen at the clinic in the past month. What is this list an example of?

A) primary data
B) data analytics
C) aggregate data
D) vital statistics

Answer 3

aggregate data

Question 4

________________ is the process of examining the data and exploring them to create information.

A) data analytics
B) epidemiology
C) aggregate data
D) vital statistics

Question 5

Electronic data are collected and organized into a:

A) database.
B) system.
C) data map.
D) data set.

Question 6

What is the first step in collecting quality data?

A) determining the needs of the users
B) creating the request for proposal (RFP)
C) looking at the data that have already been collected
D) designing a data collection form or screen

Question 7

What is the meaning of the expression, "garbage in, garbage out?"

A) all data must be collected in to discover what must be ignored
B) collecting incorrect data will result in having data that is not useful
C) quality data can only be collected by quality people
D) even bad data is useful to some users of data

Question 8

A(n) _________ field may contain both letters and numbers.

A) numeric
B) character
C) alphanumeric
D) valid

Question 9

Where would an HIM professional find a list of field names, their sizes, who collects them, and where the data is stored?

A) data repository
B) data warehouse
C) data dictionary
D) electronic health record (EHR)

Question 10

Which organizational policy would prohibit creation of EHR fields for physician-specific data collection?

A) All patient data be archived electronically.
B) All forms must be approved by the Health Records Committee.
C) All EHR data elements must comply with UHDDS
D) All EHR data elements must satisfy an organizational purpose

Question 11

What is the problem with a patient's Social Security number that is ten digits long?

A) It is not organized.
B) It is not valid.
C) It is illegal.
D) It is undefined.

Question 12

A group of fields is called a:

A) record.
B) file.
C) data dictionary.
D) character.

Question 13

A group of characters is called a:

A) record.
B) file.
C) field.
D) character.

Question 14

With what language does an HIM professional retrieve data in a relational database?

A) Structured Query Language (SQL)
B) Codasyl
C) meaningful use
D) syntactic interoperability

Question 15

How is a relational database arranged?

A) different tables linked by a common field
B) separate screens for each field
C) a summary of data dictionaries in a file
D) alphabetical strings of text in rows assigned numerically

Question 16

What is the name for the unique identifier assigned to the patient at each visit?

A) master patient index (MPI)
B) patient account number
C) medical record number (MRN)
D) Uniform Hospital Discharge Data Set (UHDDS)

Question 17

Where is the demographic data collected by patient registration stored?

A) the master patient index (MPI)
B) the data dictionary
C) the medical record number (MRN)
D) the Uniform Hospital Discharge Data Set (UHDDS)

Question 18

A standardized data set allows users of the data to:

A) compare facilities and track trends
B) identify patients who do not pay bills
C) identify physicians who charge too much
D) monitor the effects of treatments

Question 19

Which data set pertains to acute care facilities?

A) Minimum Data Set (MDS 3.0)
B) Outcome and Assessment Information Set (OASIS)
C) ICD-10-CM
D) Uniform Hospital Discharge Data Set (UHDDS)

Question 20

How do providers know what data to report in the Uniform Hospital Discharge Data Set (UHDDS)?

A) HIM professionals check a website quarterly for changes.
B) It is published in the Code of Federal Regulations (C.F.R.) each year.
C) The data elements are required fields on the Uniform Bill (UB-04).
D) Instructions are published by the entity to which the provider submits the data.

Question 21

Which data element is a required component of the UHDDS?

A) patient's eye color
B) patient's primary care provider (PCP)
C) citizenship status of patient
D) principal diagnosis

Question 22

Which data set is used in long-term care facilities?

A) Minimum Data Set (MDS 3.0)
B) Outcome and Assessment Information Set (OASIS)
C) Uniform Ambulatory Care Data Set (UACDS)
D) Uniform Hospital Discharge Data Set (UHDDS)

Question 23

All of the data that have been collected about an individual patient are called a:

A) data set.
B) file.
C) health record.
D) data repository.

Question 24

Which comparison is true of the data collected in the physician's office versus the acute care setting?

A) More people are recording patient data in the physician's office.
B) The physician's office is more likely to use electronic data collection devices.
C) More data is collected in the acute care setting.
D) The physician's office records patient progress while the acute care facility does not.

Question 25

Who develops a form?

A) the Chief Medical Officer (CMO)
B) a committee of users
C) the HIM department
D) the physician

Question 26

Which is included on every page of a form or screen?

A) patient ID
B) vital signs
C) current medications
D) provider ID

Question 27

Which is a consideration in developing a computer data collection screen that is less important in a paper form?

A) the needs of the users
B) the order in which the data is collected
C) the purpose of the data collection
D) simplicity

Question 28

Which is a benefit of electronic data collection?

A) more easily tailored to user needs
B) menus to select valid choices
C) simpler interface and design
D) automatic data transfer to accrediting bodies

Question 29

Which feature reduces the chance that a physician orders a non-approved drug?

A) electronic authentication
B) drop-down menus
C) connection to pharmacy computers
D) character limits for fields

Question 30

Which is a benefit of using forms to collect data?

A) they are easy to duplicate
B) they remind the user of what data must be collected
C) they are easy to fill out
D) they can be tailored to the needs of the patient and provider

Question 31

Where are blank original copies of forms kept?

A) in the electronic health record (EHR)
B) in the master forms file
C) at patient registration
D) in the master patient index (MPI)

Question 32

Which system do providers use to send orders?

A) the systems development life cycle (SDLC)
B) the electronic health record (EHR)
C) computerized physician order entry (CPOE)
D) the health information exchange (HIE)

Question 33

Which is characteristic of the electronic health record (EHR)?

A) the records follows the patient
B) low upfront costs
C) more secure than paper files
D) data collection at the point-of care

Question 34

Which is recommended by the clinical decision-making system (CDS)?

A) discounted medicines
B) referrals to other physicians
C) possible side effects and allergies
D) possible treatment plans

Question 35

A facility that collects some data electronically and some data on paper forms uses a(n):

A) hybrid record.
B) electronic health record (EHR).
C) electronic medical record (EMR).
D) patient portal.

Question 36

What system stores paper forms for electronic review and retrieval?

A) clinical decision-making system (CDS)
B) computerized physician order entry (CPOE) system
C) picture archiving and communication system (PACS)
D) document imaging system

Question 37

What term describes the patient's access to the electronic health record (EHR)?

A) point-of-care
B) patient portal
C) meaningful use
D) hybrid record

Question 38

How did the federal government encourage adoption of the electronic health record (EHR)?

A) Congress passed legislation requiring its use
B) Financial incentives in the form of increased payments
C) Zero-interest loans for community hospitals
D) Free computer systems for qualified providers

Question 39

Which activity is facilitated in an EHR as opposed to a hybrid record?

A) Documentation by individual providers
B) Authentication of entries at point of care
C) Concurrent review by multiple users
D) Medication administration records

Question 40

A network of various health care providers with access to each other's patient records from approved points of care is a:

A) computerized physician order entry (CPOE).
B) health information exchange (HIE).
C) electronic document management system (EDMS).
D) master patient index (MPI).

Question 41

Interoperability means:

A) the ability to share data among different computer systems.
B) incentives for electronic health record (EHR) adoption.
C) efforts to use the same computers nation-wide.
D) surgery performed remotely using robots.

Question 42

Health Level Seven (HL7) is a:

A) committee working on EHRs for hospitals within the Veteran's Administration (VA).
B) committee established by the President of the United States to investigate the use of EHRs.
C) health clinic for seven boroughs in New York City.
D) standards development organization whose domain is clinical and administrative data.

Question 43

The Office of the National Coordinator for Health Information Technology (ONC) supports the development of the Nationwide Health Information Network (NHIN), which is a:

A) set of standards and policies.
B) series of networked computers.
C) centrally located data repository.
D) cloud-based EHR software suite.

Question 44

What is a benefit to an interoperable nationwide health information network (NHIN)?

A) continuity of care
B) more secure records
C) less training for health care professionals
D) physicians spend less time entering orders.

Question 45

Which entity fostered collaboration between the public sector and private sector to develop standards for the exchange of electronic medical information?

A) Institute of Medicine
B) National Committee on Vital and Health Statistics
C) Markle Foundation
D) Consolidated Health Informatics

Question 46

Which standard supports the storage and transmission of diagnostic images?

A) picture archiving and communication system (PACS)
B) Health-Level 7 (HL7)
C) 837I
D) Digital Imaging and Communication in Medicine (DICOM)

Question 47

A(n) _____________ can store the data from these different systems and make them usable through an interface without the need to run reports from each system.

A) data repository
B) data warehouse
C) health information exchange (HIE)
D) data mapper

Question 48

A(n) ______________ collects information from different databases and organizes it for use in creating reports and for analytical research.

A) electronic data interchange (EDI)
B) health information exchange (HIE)
C) electronic document management system (EDMS)
D) secure messaging system (SMS)

Question 49

The EHR software is chosen after considering the needs of the _________, or those who will use and maintain the system.

A) employees
B) selection committee
C) HIM department
D) stakeholders

Question 50

The standard operating nomenclature, specifications, or protocols of a system is called the:

A) electronic data interchange (EDI).
B) interface.
C) infrastructure.
D) relational database.

Question 51

Which is another term for data quality?

A) data integrity
B) data authentication
C) data definition
D) data imaging

Question 52

The smallest elements or units of facts or observations is ________.

Question 53

The abbreviation for the data set used in home health settings is __________.

Question 54

The development, implementation, and enforcement of policies and procedures that ensure that standards are met is __________.

Question 55

A ___________ is a mark indicating that a subordinate's work has been supervised.

Question 56

The clinical decision-making system (CDS) in an EHR is based on _____________-based medicine, a methodology for patient care that makes conscientious, explicit, and judicious use of current best research.

Question 57

When two or more systems can exchange information and interpret the meaning of the information exchanged without any ambiguity, it is called ___________ interoperability.

Question 58

The individual's separate health record containing information owned and managed by the patient is called the ___________ health record.

Question 59

Data ___________ is the matching of a data element in one system or database to the same element in another system or database.

Question 60

The process used to plan, design, develop, implement, and maintain an information system is called the system development _______________ cycle.

Question 61

An individual trained in all aspects of a computer system who can offer on-site support to others is called a _________.