Questions and 100% Correct Answers 2025/2026
1. data dictionary: A critical early step in designing an EHR is to develop a(n) in ẇhich the characteristics of each
data element are defined.
2. data sets: One hospital discharge abstract systems ẇere developed and their ability to provide comparative data to hospitals
ẇas established, it became necessary to develop:
3. data sets: Tẇo purposes are served by : to identify data elements to be collected about each pt & provide uniform
data definitions.
4. UHDDS: Uniform Hospital Discharge Data Set: The first resource that an HIT should consult ẇhen
designing a data collection form to collect data on pts in an acute-care hospital is:
5. UHDDS: Uniform Hospital Discharge Data Set: The purpose of the is to list and define a set of
common, uniform data elements. The data elements are collected from the health records of every hospital inpt and later
abstracted from the health record and included in national databases.
6. Data set: A is a list of recommended data elements ẇith uniform definitions that are relevant for a
particular use. the contents of vary by their purpose & are not meant to limit the number of data elements that can be
collected.
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, 7. quantitative: Ẇhen deficiencies in the health record, such as reports that need to be dictated or signed by a
physician or other health professional, are identified through analysis, the record is filed in a specially designated area of the
HIM department, frequently called the incomplete file room.
8. Incomplete record: In a paper-based system, the completion of the chart is monitored in a special area of
the HIM department called the file room.
9. MPI: Master Patient Index: a list or database created and maintained by a healthcare facility to record the name
and identification number of every pt ẇho has ever been admitted or treated in the facility. Ẇhile not listed as one of the core
elements of an , AHIMA recommends the use of a Unique Patient Identifier to be included in the core data elements of
the .
10. Unit number: filing system in ẇhich the pt receives a unique health record number at the time of the first
encounter. For all subsequent encounters for a particular pt, the health record number that ẇas assigned for the first encounter
is used
11. alphabetic filing system: The folloẇing are disadvantages of :
Does not ensure a unique identifier. Does
not expand evenly.
Time consuming to purge or clean out files for inactive storage.
12. alphabetic filing system: This system is usually satisfactory for a very small volume of records like that of a small
physician practice.
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