Deck 2: Collecting Health Care Data

Question 1

Which of the following is NOT an example of clinical data?

A) Appendectomy 3 years ago
B) Smokes two packs of cigarettes daily
C) Blood pressure
D) Wears glasses to read

Answer 1

Smokes two packs of cigarettes daily

Question 2

"Rule out Congestive Heart Failure versus Cerebrovascular Accident" is an example of which of the following components of medical decision making?

A) Subjective
B) Objective
C) Assessment
D) Plan

Answer 2

Assessment

Question 3

Dr. Smith is a physician in general, or family, practice. He and his partner, Dr. Wong, are evaluating the way they organize their paper record documentation. They have a large number of patients, many of whom have multiple, chronic illnesses. The doctors would like to organize their records to make it easier to see what has been done with respect to each patient's illness. As their office manager, what do you recommend?

A) Source-oriented record
B) Integrated record
C) Problem-oriented record
D) Use the organization method that works best for each patient.

Answer 3

Problem-oriented record

Question 4

All of the following are examples of demographic data EXCEPT:

A) Birth date
B) Home telephone number
C) Occupation
D) Social Security number

Question 5

"Pupils equal, round, and reactive to light and accommodation" is an example of which of the following components of medical decision making?

A) Subjective
B) Objective
C) Assessment
D) Plan

Question 6

In creating a data collection device, which of the following is the most important consideration?

A) Purpose of the form
B) The size of the paper or the computer screen
C) The number of fields on the page
D) Joint Commission rules regarding forms creation

Question 7

Your facility is using a paper-based record. The HIM department has decided to switch from an integrated record to a completely source-oriented record, postdischarge. You are responsible for training the staff members who assemble the records into the correct order. Which of the following must exist in order to implement this change?

A) All documentation must be changed to reflect the new order.
B) Except for physician's orders, physicians and nurses cannot document on the same page.
C) Nothing has to change; the way the clinicians document information is irrelevant to the chart order.
D) Physicians and nurses must document on the same page.

Question 8

Which of the following is NOT a benefit of a problem list?

A) Reduces the amount of documentation in the record
B) Facilitates management of the patient's care
C) Improves communication among caregivers
D) Creates an index to the patient's record

Question 9

A patient presented in the emergency department with unusual lesions on the skin, a fever, and dehydration. Of the following types of data, which will be most helpful to the physician in developing a list of potential diagnoses?

A) Demographic data
B) Indicative data
C) Socioeconomic data
D) Financial data

Question 10

The individual or organization that is ultimately responsible for paying a hospital bill is called the:

A) Employer
B) Guarantor
C) Patient
D) Spouse

Question 11

The study of health trends or patterns is called:

A) Demographic data
B) Epidemiology
C) Health data
D) Health information

Question 12

"Chest x-ray to rule out CHF" is an example of which of the following components of medical decision making?

A) Subjective
B) Objective
C) Assessment
D) Plan

Question 13

"Patient complains of dizziness and shortness of breath" is an example of which of the following components of medical decision making?

A) Subjective
B) Objective
C) Assessment
D) Plan

Question 14

Which of the following is NOT an example of the possible contents of a 2 character state field?

A) F
B) FL
C) DC
D) NM

Question 15

Data that have been processed into a useful frame of reference is called

A) Observation
B) Information
C) Schedule
D) Assessment

Question 16

If a patient's insurance company has reimbursed the physician for the appropriate amount and there is still a balance due in the patient's account, the physician must apply next for payment to the:

A) Guarantor
B) State government
C) Medicaid
D) Patient's parents

Question 17

The result of a plan of treatment is called the:

A) Assessment
B) Outcome
C) Diagnosis
D) Health record

Question 18

Which of the following is an example of demographic data?

A) Address
B) Marital status
C) Race
D) Employer

Question 19

In which step of the medical decision-making process can the following statement be found? "Patient's BP 120/75, rule out hypertension"

A) Subjective
B) Objective
C) Assessment
D) Plan

Question 20

Another term for demographic data is:

A) Explanatory
B) Referral
C) Global
D) Indicative

Question 21

Maintaining a problem list is a requirement for accreditation by which agency?

A) CMS
B) AHIMA
C) TJC
D) UHDDS

Question 22

The nurse took the patient's temperature and found it to be 97.6° F. She wrote "96.7" in the chart. This entry fails the data quality criterion of:

A) Timeliness
B) Accuracy
C) Validity
D) Completeness

Question 23

All of the following are components of a problem list EXCEPT:

A) Diagnoses
B) Date of initial diagnosis
C) Procedures
D) Discharge date

Question 24

The integrated record is organized by:

A) Source
B) Date
C) Alphabetical order
D) Numerical order

Question 25

Which of the following would be considered socioeconomic data?

A) Gender
B) Marital status
C) Income bracket
D) Diagnosis

Question 26

Which of the following data sets is used by acute care facilities?

A) MDS
B) OASIS
C) ICD-10-CM
D) UHDDS

Question 27

What consideration is more important when creating an electronic data collection screen than it is in a paper form?

A) Size of the fields
B) Number of fields on a page
C) Definition or description of the fields
D) Sequence of data entry into the fields

Question 28

Vital statistics could be which of the following?

A) Date of birth
B) Date of mother's birth
C) Date of father's death
D) Date of first menses

Question 29

In creating an electronic data collection screen, which of the following is the most important consideration?

A) Purpose of the data collection
B) The size of the computer screen
C) The number of fields on the page
D) Joint Commission rules regarding forms creation

Question 30

All of the following are considered data sets EXCEPT:

A) UHDDS
B) OASIS
C) CMS
D) MDS

Question 31

Authentication shows:

A) The person responsible for the data on a form
B) The name of the facility and its logo
C) The patient's name or barcode
D) The title and number of the form

Question 32

A synonym for an integrated record is:

A) Date-oriented
B) Sequential
C) Source-oriented
D) Both a and b

Question 33

The nurse took the patient's temperature and found it to be 97.6° F. She entered "976" in the computer. The computer program displayed an error message. What was the computer program checking?

A) Timeliness
B) Accuracy
C) Validity
D) Completeness

Question 34

All of the following are advantages to the use of Electronic Health Records EXCEPT which one?

A) Manage information timely and efficiently.
B) Use of computerized physician order entry (CPOE).
C) Ability to capture electronic signatures.
D) Unauthorized users may access patient information at any time.

Question 35

An electronic health care system that allows physicians to enter their orders through a computer is called:

A) Barcode Medication Administration
B) Electronic Health Record
C) ADT
D) CPOE

Question 36

Which of the following data would not be considered relevant to the patient's health data?

A) Marital status
B) Health status of parents
C) Eye color
D) Blood type

Question 37

According to your text, race is an example of ____ data.

A) Demographic
B) Socioeconomic
C) Financial
D) Clinical

Question 38

The data contained in the MPI, used to identify each patient and to locate the patient's health record, is called:

A) Data dictionary
B) Face sheet
C) Demographic data
D) Financial data

Question 39

SOAP notes are examples of ____ data.

A) Demographic
B) Socioeconomic
C) Financial
D) Clinical

Question 40

A record that is organized by the patient's health problems is called a(n) _____ record.

A) Problem-oriented
B) Source-oriented
C) Integrated
D) Electronic health

Question 41

List and describe the four general categories of health data and list two examples of each type of data.

Question 42

The quality that data reflect the known or acceptable range of values for the specific data is called data ________.

Question 43

Data collected for the purpose of patient identification is ________ data.

Question 44

Describing Data

Use the sample data descriptions above to answer the following question.
Using 12 alphanumerical characters is one way to capture the patient's home telephone number. List at least one other way to capture that data.

Question 45

Data that pertain to the patient's personal life and personal habits, such as marital status and religion, is called _______ data.

Question 46

Give two examples of how data become information.

Question 47

The smallest element or unit of knowledge is ________.

Question 48

A listing of all fields and their definitions is called a ________.

Question 49

The following statement will be found in the ________ step of medical decision making.
"Patient states dizziness and shortness of breath."

Question 50

A collection or series of related characters is a ________.

Question 51

The study of disease trends and occurrences is _______.

Question 52

The quality of data being correct is called ________.

Question 53

Data collected about the party who will pay for the patient's health care is _______ data.

Question 54

Public health data collected through birth certificates, death certificates, and other data gathering tools are called _______ statistics.

Question 55

How does the quantity of health data affect our understanding of what it contains?

Question 56

In a database, a list of details about each field is a data _______.

Question 57

A single letter, number, or symbol is a ________.

Question 58

Describing Data

Use the sample data descriptions above to answer the following question.
List and describe two additional fields that would be needed to capture a patient's entire name.

Question 59

Data collected pertaining to the investigation of the patient's current health situation is called _______ data.

Question 60

After all other payment sources are exhausted, the _______ is responsible for the remaining balance of payments.

Question 61

In your own words, describe what conditions must exist in order for a person to be "healthy."

Question 62

How can the accuracy, validity, and completeness of data be improved as it is being collected?

Question 63

Medical forms design is an essential task for HIM professionals. What factors need to be considered? Name at least two.

Question 64

Explain how a health information technician ensures the quality of the health information database.

Question 65

What vital information fields would a medication administration form contain? Name at least five fields.

Question 66

Define characters, fields, records, and files. Give two examples of each.

Question 67

How can data collection devices affect the quality of data? Give examples.

Question 68

Name three elements that may be collected as socioeconomic data and explain why this type of data is important.

Question 69

Explain the difference between a data set and a database. Give an example of each.

Question 70

What is the difference between data and information?

Question 71

How can a large quantity of health data be communicated in a meaningful way (as information)?

Question 72

List and describe at least three different characteristics of data quality.

Question 73

What is the difference between mortality and morbidity?

Question 74

Why is it important to have a standard to collect data when organizing and analyzing data?