QUESTIONS & CORRECT VERIFIED ANSWERS
1. What document defines how records and documentation are assembled
and authenticates within the hospital? (Chpt 6) ANS >> Medical staff bylaws
2. What concept refers to the process of creating management and oversight
of data assets to support the organization's mission, vision, and values? (Chpt
6) ANS >> Information governance
3. A patient's birth date and gender documented in the health record are
examples of a data? (Chpt 6) ANS >> Element
4. Which index is used by the HIM department to link the patient's name and
number in relations to access and retention of the clinical record? (Chpt
6) ANS >> Master patient index
5. What are the names of the standard development organizations that focus
on creating standards in the following areas ANS >>
1. Exchange of clinical information
2. Messaging of digital images (Chpt 6) ANS >> 1. HL 7 (health level 7)
2. DICOM
6. A/n is a list that provides guidance, indication, or other
references of information contained in a database? (Chpt 6) ANS >> Index
7. What is another term for the electronic sharing of patient data between two
healthcare systems? (Chpt 6) ANS >> Health information exchange
8. The characteristic of quality data is the data being com-
pletely free from any errors? (Chpt 6) ANS >> Accuracy
9. What describes the capability for 2 or more electronic systems to commu-
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, nicate and exchange information electronically? (Chpt 6) ANS >>
Interoperability
10. Safeguards established to support the data is available when and where is
it needed under the data quality model is called what? (Chpt 6) ANS >>
Accessibility
11. A/n is a communication tool that during clinical
documentation improvement is used to communicate between a clinical doc-
umentation improvement professional and the provider? (Chpt 6) ANS >>
Query
12. The process of completing an inventory of all electronic systems that cre-
ate, transmit, and store health information is known as what? (Chpt 6) ANS >>
System characterization
13. A health information manager took the three elements, blood pressure,
weight, ans cholesterol to analyze for potential indicators of a heart attack.
The combined data is referred to as? (Chpt 6) ANS >> Information
14. What creates a visual process to understand the data being collected to 2
different systems and how it is linked to one another? (Chpt 6) ANS >> Data
mapping
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, 15. What is a collection of data that is organized in a manner to be accessed,
managed, reported, and updated electronically? (Chpt 6) ANS >> Database
16. What is an example of an electronic data source? (Chpt 6) ANS >> Electronic
Health Record (EHR)
17. What is a data set created to collect uniform data across the US for
inpatient patient stays? (Chpt 6) ANS >> Uniform Hospital Discharge Set
(UHDDS)
18. A single or individual fact that represents a patient in healthcare is known
as a/n . (Chpt 6) ANS >> Data element
19. 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 . (Chpt
6) ANS >> Facility's data dictionary
20. Data field, definition, data type, and format are all common data elements
in what? (Chpt 6) ANS >> Data dictionary
21. Using a template to collect data for key reports may help to prompt
caregivers to document all required data elements in the patient record. This
practice contributes to data . (Chpt 6) ANS >>
Comprehensiveness
22. What is a term that describes the data that defines and characterizes other
data within an electronic system? (Chpt 6) ANS >> Metadata
23. What data quality characteristic is met when documenting the specific
height of a patient within the health record? (Chpt 6) ANS >> Precision
24. The term that refers to an individual's ability to analyze, assess, and re-
construct a situation to provide a solution is . (Chpt 6) ANS >>
Critical thinking
25. The process that focuses on the improving the quality and integrity of
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