Questions And Correct
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Primary Data Source -ANSWER Patient specific/identifiable data
Related to a specific individual
ex. The Health Record
Secondary Data Source -ANSWER Information on groups of people or patients without
identifying any particular patient individually.
Also called "Aggregate Data"
Compiled from multiple health records
Ex. Data taken from the health record and entered into registries and databases are
considered secondary data.
Confidentiality -ANSWER ...
Security -ANSWER ...
Privacy -ANSWER ...
Quantitative Analysis -ANSWER Checking for the presence or absence of necessary
reports or signatures. Ex. progress notes, orders
Completeness and Accuracy
Making sure a document is there and authenticated
Focuses on physician documentation
Qualitative Analysis -ANSWER Ex. Checking documentation consistency, such as
contraindications in entries,progress note dated prior to admission etc
Quality of records
Does documentation reflect the quality of patient care provided
Incident Report -ANSWER Written accounts of unusual events that have an adverse
effect on a patient, employee, or facility visitor.
Never filed in patient health record.
Used by risk management and or attorney to investigate incidents that have the
potential to become claims against the organization or individual provider.
Incident -ANSWER An event considered to be inconsistent with accepted standards of
care.
Ex.
res ipsa loquitor -ANSWER "the thing speaks for itself"
, The injury would not ordinarily occur without someones negligence Ex. Surgical
instrument left in patient after surgery
Currency -ANSWER ...
Data Accessibility -ANSWER data is available to those authorized to use it
Relevancy -ANSWER ...
Consistency -ANSWER ...
Benchmarking -ANSWER Process of comparing an organization to a standard, a peer
group, or other organization.
Ex. A hospital may want to compare its ALOS (average length of stay) with the ALOS
for all hospitals nationwide.
Continuum Of Care -ANSWER Various types of healthcare services provided in diverse
settings from basic primary care to complex tertiary settings.
Primary Care -ANSWER Services provided by physicians working in private offices,
group practices, private clinics or community based clinics.
Ex Family practice, pediatrics
Ex of primary care services: preventative,routine screening,physical exams
Secondary Care -ANSWER Diagnostic and theraputic services provided by medical
specialists.
Tertiary Care -ANSWER The provision of highly specialized and advanced diagnostic
and therapeutic services in inpatient hospital settings.
The medical record is the property of the ........ -ANSWER facility/institution
The information in the medical record is owned by the..... -ANSWER patient
Legal Health record -ANSWER Official business record of the healthcare orginization
Derived Data -ANSWER Health information collected from health records
No patient identifiers
Data -ANSWER Raw facts and figures expressed in test, numbers symbols and figures
Information -ANSWER Data processed into meaningful form
Physician Index -ANSWER Categorizes patient encounters by physicians
Registry -ANSWER Database of patients that have a common characteristic