QUESTIONS GRADED A+
◍ Standardizing medical terminology to avoid differences in naming
various health conditions and procedures (such as the synonyms
bunionectomy, McBride procedure, and repair of hallux valgus) is one
purpose of:
a. Content and structure standards
b. Security standard
c. Transaction standards
d. Vocabulary standards. Answer: d. Vocabulary standards
Vocabulary standards are a list or collection of clinical words or
phrases with their meanings; also, the set of words used by an
individual or group within a particular subject field, such as to
provide consistent descriptions of medical terms for an individual's
condition in the health record.
◍ Patient care managers use the data documented in the health record
to:
a. Determine the extent and effects of occupational hazards
b. Evaluate patterns and trends of patient care
c. Generate patient bills and third-party payer claims for
reimbursement
,d. Provide direct patient care. Answer: b. Evaluate patterns and trends
of patient care
Patient care managers are responsible for the overall evaluation of
services rendered for their particular area of responsibility. To identify
patterns and trends, they take details from individual health records
and put all the information together in one place.
◍ At admission, Mrs. Smith's date of birth is recorded as 3/25/1948.
An audit of the EHR discovers that the numbers in the date of birth
are transposed in reports. This situation reflects a problem in:
a. Data comprehensiveness
b. Data consistency
c. Data currency
d. Data granularity. Answer: b. Data consistency
Consistency means ensuring the patient data is reliable and the same
across the entire patient encounter. In other words, patient data within
the record should be the same and should not contradict other data
also in the patient record.
◍ A health data analyst has been asked to compile a listing of daily
blood pressure readings for patients with a diagnosis of hypertension
who were treated on the medical unit within a two-week period. What
clinical report would be the best source to gather this information?
,a. Vital signs record
b. Initial nursing assessment record
c. Physician progress notes
d. Admission record. Answer: a. Vital signs record
The vital signs record is comprised of blood pressure readings,
temperature, respiration, and pulse, making it the best source to gather
this type of information.
◍ Which of the following is a key characteristic of the problem-
oriented health record?
a. Allows all providers to document in the health record
b. Uses laboratory reports and other diagnostic tools to determine
health problems
c. Provides electronic documentation in the health record
d. Uses an itemized list of the patient's past and present health
problems. Answer: d. Uses an itemized list of the patient's past and
present health problems
The problem-oriented health record is better suited to serve the patient
and the end user of the patient's information. The key characteristic of
this format is an itemized list of the patient's past and present social,
psychological, and health problems.
, ◍ Which of the following is true regarding the reporting of
communicable diseases?
a. They must be reported by the patient to the health department.
b. The diseases to be reported are established by state law.
c. The diseases to be reported are established by HIPAA.
d. They are never reported because it would violate the patient's
privacy.. Answer: b. The diseases to be reported are established by
state law.
All states have a health department with a division that is required to
track and record communicable diseases. When a patient is diagnosed
with one of the diseases from the health department's communicable
disease list, the facility must notify the state public health department.
◍ A new health information management (HIM) director has been
asked by the hospital CIO to ensure data content standards are
identified, understood, implemented, and managed for the hospital's
EHR system. Which of the following should be the HIM director's
first step in carrying out this responsibility?
a. Call the EHR vendor and ask to review the system's data dictionary
b. Identify data content requirements for all areas of the organization
c. Schedule a meeting with all department directors to get their input
d. Contact CMS to determine what data sets are required to be
collected. Answer: b. Identify data content requirements for all areas
of the organization