RHIT-Domain 1-Domain 1: Data Content, Structure, and Information Governance

RHIT-Domain 1-Domain 1: Data Content, Structure, and Information Governance Data Sets and Data Elements 1. What is the primary purpose of a data set in healthcare? Answer: To recommend common data elements to be collected in health records. 2. Which data set is used to develop care plans for residents in long-term care facilities? Answer: Minimum Data Set (MDS). 3. What is the main purpose of the Uniform Hospital Discharge Data Set (UHDDS)? Answer: To provide a list of recommended data elements with uniform definitions for hospital discharges. 4. Which data set is used to collect data on Medicare beneficiaries receiving services from home health agencies? Answer: Outcomes and Assessment Information Set (OASIS-C). 5. What is the purpose of the Healthcare Effectiveness Data and Information Set (HEDIS)? Answer: To organize data about public health issues to inform purchasers and consumers about the performance of healthcare plans. Data Quality 6. What is missing from Dr. Jones' progress note? Answer: Data currency. 7. What does "data currency" refer to in healthcare data quality? Answer: The timeliness of the documentation or data entry. Standards and Interoperability 8. What type of standard provides clear guidelines for acceptable values of specific data fields? Answer: Data content standard. 9. Which standard provides clear descriptors of data elements to be included in an electronic health record system? Answer: Vocabulary standard. 10. What type of standards make it possible to exchange health information using electronic networks? Answer: Interoperability standards. Record Content and Quality 11. Where would you typically find documentation about social work services provided to a patient? Answer: Social service notes. 12. What quality element is related to the timeliness of documentation or data entry? Answer: Data currency. Cancer registries receive approval as part of the facility cancer program from which of the following agencies? a.American Cancer Society b.National Cancer Registrar's Association c.National Cancer Institute d.American College of Surgeons ️D) several organizations have developed standards or approval processes for cancer programs. The American College of Surgeons (ACS) Commission on Cancer has an approval process for cancer programs. One of the requirements of this process is the existence of a cancer registry as part of the program Which one of the following indexes contains a list maintained in procedure code number order for patients who are discharged from a facility during a particular time period? a.Physician b.Master patient c.Disease d.Operation ️D) The Operation Index is similar to the Disease Index except that it is arranged in numerical order by the patient's procedure code(s) using International Classification of Diseases or Current Procedural Terminology (CPT) codes HIM departments may be the hub of identifying, mitigating, and correcting MPI errors, but that information often is not shared with other departments within the healthcare organization. After identifying procedural problems with admitting patients that contribute to the creation of the MPI errors, which department should the MPI manager work with to correct these procedural problems? a.Administration b.Registration c.Risk Management d.Radiology and Laboratory ️B) A review of the identified duplicates and overlays often reveals procedural problems that contribute to the creation of errors. Although health information management (HIM) departments may be the hub of identifying, mitigating, and correcting master patient index (MPI) errors, that information may never be shared with the registration department. If the registration staff is not aware of the errors, how can they begin to proactively prevent the errors from occurring in the first place? Registration process improvement activities can eventually reduce work for HIM departments. In addition, monitoring new duplicates is a critical process, and tracking reports should be created and implemented. Identifying and reporting MPI errors is important; however, tracking who made the error and why will decrease the number of duplicates OASIS-C data are used to assess the _________ of home health services. a.Core measure b.Financial performance c.Outcome d.Utilization ️C) The Outcomes and Assessment Information Set (OASIS-C) consists of data elements that represent core items for the comprehensive assessment of an adult home care patient and form the basis for measuring patient outcomes for the purpose of outcome-based quality improvement