HEALTH DATA CONTENT AND STANDARDS FINAL
QUIZ |100% CORRECT ANSWERS GRADED A+ | LATEST
2025 UPDATE
1. Which of the following is a form or view that is typically seen in the health
record of a long-term care patient but is rarely seen in records of acute care
patients? ANS >> pharmacy consultation
NOTE ANS >> Pharmacy consults are required for elderly patients who typically
take multiple medications. These consults review for potential drug interactions
and/or discrepancies in medications given and those ordered.
2. The health care providers at your hospital do a very thorough job of periodic
open record review to ensure the completeness of record documentation.
A qualitative review of surgical records would likely include checking for
documentation regarding ANS >> the presence or absence of such items as
preoperative and postoperative diagnosis, description of findings, and specimens
removed.
NOTE ANS >> "Whether a postoperative infection occurred and how it was treated"
repre- sents an appropriate job for the infection control officer. "The quality of
follow-up care" represents the clinical care evaluation process, rather than the
review of quality documentation. "Whether the severity of illness and/or intensity of
service warranted acute level care" is a function of the utilization review program.
The correct answer is "the presence or absence of such items as preoperative and
postoperative diagnosis, description of findings, and specimens removed."
3. The 2014 AHIMA Foundation's "Clinical Documentation Improvement Job
Description Summative Report" identified that most clinical documentation
improvement specialists report directly to the ANS >> HIM Department
NOTE ANS >> Although CDI programs differ in hierarchy, MOST CDS professionals
report to the HIM department, according to the Foundation report.
4. The master patient index must, at a minimum, include sufficient information
https://www.stuvia.com/user/Mboffin
, to ANS >> uniquely identify the patient.
NOTE ANS >> The MPI contains information regarding all patients seen at the
facility. The MPI is never destroyed. It is retained permanently. Unique identification
may include a unique medical record number for each patient (e.g., social security
number), name, date of birth, sex, address, a photograph, or/and other personal
immutable properties.
5. In determining your acute care facility's degree of compliance with prospec-
tive payment requirements for Medicare, the best resource to reference for
recent certification standards is the ANS >> Federal Register.
NOTE ANS >> CMS publishes both proposed and final rules for the Conditions of
Participa- tion for hospitals in the daily Federal Register.
6. The health record states that the patient is a female, but the registration
record has the patient listed as male. Which of the following characteristics of
data quality has been compromised in this case? ANS >> data accuracy
NOTE ANS >> Data accuracy denotes that data are correct values, so that is the
correct
https://www.stuvia.com/user/Mboffin
, choice. Data comprehensiveness denotes that all data items are included. Data
granularity denotes that the attributes and values of data should be defined at the
correct level of detail. Data precision denotes that data values should be just large
enough to support the application of process.
7. Protected health information includes ANS >> individually identifiable health
informa- tion in any format stored by a health care provider or business associate.
NOTES ANS >> PHI includes all individually identified health information, regardless
of format. ePHI, however, includes only electronic PHI.
8. A retrospective review as part of quality improvement activities is conduct-
ed after the patient has been ANS >> discharged.
NOTE ANS >> Retrospective means past. Therefore, a retrospective review is
conducted after the patient has been discharged.
9. As the chair of a Forms Review Committee, you need to track the field name
of a particular data field and the security levels applicable to that field. Your
best source for this information would be the ANS >> facility's data dictionary.
NOTE ANS >> "MDS" and "UHDDS" are types of data sets for collecting data in
long-term (MDS) and acute care (UHDDS) facilities. A data dictionary should
include security levels for each field as well as definitions for all entities.
10. The first patient with cancer seen in your facility on January 1, 2018 was
diagnosed with colon cancer with no known history of previous malignancies.
The accession number assigned to this patient is ANS >> 18-0001/00.
NOTE ANS >> In accession number 18-0001/00, "18" represents the year that the
patient first entered the database; "0001" indicates that this was the first case
entered that year; "00" indicates that this patient has only one known neoplasm.
11. According to the following table, the most serious record delinquency
problem occurred in which of the following months? ANS >> April
NOTE ANS >> A recommendation for improvement from Joint Commission is
https://www.stuvia.com/user/Mboffin
QUIZ |100% CORRECT ANSWERS GRADED A+ | LATEST
2025 UPDATE
1. Which of the following is a form or view that is typically seen in the health
record of a long-term care patient but is rarely seen in records of acute care
patients? ANS >> pharmacy consultation
NOTE ANS >> Pharmacy consults are required for elderly patients who typically
take multiple medications. These consults review for potential drug interactions
and/or discrepancies in medications given and those ordered.
2. The health care providers at your hospital do a very thorough job of periodic
open record review to ensure the completeness of record documentation.
A qualitative review of surgical records would likely include checking for
documentation regarding ANS >> the presence or absence of such items as
preoperative and postoperative diagnosis, description of findings, and specimens
removed.
NOTE ANS >> "Whether a postoperative infection occurred and how it was treated"
repre- sents an appropriate job for the infection control officer. "The quality of
follow-up care" represents the clinical care evaluation process, rather than the
review of quality documentation. "Whether the severity of illness and/or intensity of
service warranted acute level care" is a function of the utilization review program.
The correct answer is "the presence or absence of such items as preoperative and
postoperative diagnosis, description of findings, and specimens removed."
3. The 2014 AHIMA Foundation's "Clinical Documentation Improvement Job
Description Summative Report" identified that most clinical documentation
improvement specialists report directly to the ANS >> HIM Department
NOTE ANS >> Although CDI programs differ in hierarchy, MOST CDS professionals
report to the HIM department, according to the Foundation report.
4. The master patient index must, at a minimum, include sufficient information
https://www.stuvia.com/user/Mboffin
, to ANS >> uniquely identify the patient.
NOTE ANS >> The MPI contains information regarding all patients seen at the
facility. The MPI is never destroyed. It is retained permanently. Unique identification
may include a unique medical record number for each patient (e.g., social security
number), name, date of birth, sex, address, a photograph, or/and other personal
immutable properties.
5. In determining your acute care facility's degree of compliance with prospec-
tive payment requirements for Medicare, the best resource to reference for
recent certification standards is the ANS >> Federal Register.
NOTE ANS >> CMS publishes both proposed and final rules for the Conditions of
Participa- tion for hospitals in the daily Federal Register.
6. The health record states that the patient is a female, but the registration
record has the patient listed as male. Which of the following characteristics of
data quality has been compromised in this case? ANS >> data accuracy
NOTE ANS >> Data accuracy denotes that data are correct values, so that is the
correct
https://www.stuvia.com/user/Mboffin
, choice. Data comprehensiveness denotes that all data items are included. Data
granularity denotes that the attributes and values of data should be defined at the
correct level of detail. Data precision denotes that data values should be just large
enough to support the application of process.
7. Protected health information includes ANS >> individually identifiable health
informa- tion in any format stored by a health care provider or business associate.
NOTES ANS >> PHI includes all individually identified health information, regardless
of format. ePHI, however, includes only electronic PHI.
8. A retrospective review as part of quality improvement activities is conduct-
ed after the patient has been ANS >> discharged.
NOTE ANS >> Retrospective means past. Therefore, a retrospective review is
conducted after the patient has been discharged.
9. As the chair of a Forms Review Committee, you need to track the field name
of a particular data field and the security levels applicable to that field. Your
best source for this information would be the ANS >> facility's data dictionary.
NOTE ANS >> "MDS" and "UHDDS" are types of data sets for collecting data in
long-term (MDS) and acute care (UHDDS) facilities. A data dictionary should
include security levels for each field as well as definitions for all entities.
10. The first patient with cancer seen in your facility on January 1, 2018 was
diagnosed with colon cancer with no known history of previous malignancies.
The accession number assigned to this patient is ANS >> 18-0001/00.
NOTE ANS >> In accession number 18-0001/00, "18" represents the year that the
patient first entered the database; "0001" indicates that this was the first case
entered that year; "00" indicates that this patient has only one known neoplasm.
11. According to the following table, the most serious record delinquency
problem occurred in which of the following months? ANS >> April
NOTE ANS >> A recommendation for improvement from Joint Commission is
https://www.stuvia.com/user/Mboffin
