©JOSHCLAY 2024/2025. YEAR PUBLISHED, 2024.
Health Data Content Standards Exam
Questions and Answers 100% Solved
In preparation for an EHR, you are conducting a total facility inventory of all
forms currently used. You must name each form for bar coding and
indexing into a document management system. The unnamed document in
front of you includes a microscopic description of tissue excised during
surgery. The document type you are most likely to give this form is: -
✔✔B. Pathology Report
Patient data collection requirements vary according to health care setting
vary according to health care setting. A data element you would expect to
be collected in the MDS, but NOT the UHDDS would be? - ✔✔B.
Cognitive Patterns
In the past, Joint Commission standards have focused on promoting the
use of a facility-approved abbreviation list to be used by hospital care
providers. With the advent of the Commission's national patient safety
goals, the focus has shifted to the: - ✔✔C. Use of prohibited or
"dangerous" abbreviations
,©JOSHCLAY 2024/2025. YEAR PUBLISHED, 2024.
Engaging patients and their families in health care decisions is one of the
core objectives for: - ✔✔A. achieving meaningful use of EHRs
A risk manager needs to locate a full report of a patient's fall from his bed,
including witness reports and probable reason for the fall. She would most
likely find this information in the: - ✔✔C. incident report
For continuity of care, ambulatory care providers are more likely than
providers of acute care services to rely on the documentation found in the: -
✔✔D. problem list
Joint Commission does not approve of auto authentication of entries in a
health record. The primary objection to this practice is that: - ✔✔B.
evidence cannot be provided that the physician actually reviewed and
approved each report
As part of a quality improvement study, you have been asked to provide
information on the menstrual history, number of pregnancies, and number
of living children on each OB patient from a stack of old obstetrical records.
The best place in the record to locate this information is the: - ✔✔A.
antepartum record
As a concurrent record reviewer for an acute care facility, you have asked
Dr. Crossman to provide an updated history and physical for one of her
, ©JOSHCLAY 2024/2025. YEAR PUBLISHED, 2024.
recent admissions. Dr. Crossman pages through the medical record to a
copy of an H&P performed in her office a week before admission. You tell
Dr. Crossman: - ✔✔C. the H&P copy is acceptable as long as she
documents any interval changes
You have been asked to identify every reportable case of cancer from the
previous year. A key resource will be the facility's: - ✔✔A. disease index
Joint Commission requires the attending physician to countersign health
record documentation that is entered by: - ✔✔A. interns or medical
students
The minimum length of time for retaining original medical records is
primarily governed by: - ✔✔C. state law
The use of personal signature stamps for authentication of entries in a
paper-based record requires special measures to guard against delegated
use of the stamp. In a completely computerized patient record system,
similar measures might be utilized to govern the use of: - ✔✔D.
electronic signatures
Discharge summary documentation must include: - ✔✔C. significant
findings during hospitalization
Health Data Content Standards Exam
Questions and Answers 100% Solved
In preparation for an EHR, you are conducting a total facility inventory of all
forms currently used. You must name each form for bar coding and
indexing into a document management system. The unnamed document in
front of you includes a microscopic description of tissue excised during
surgery. The document type you are most likely to give this form is: -
✔✔B. Pathology Report
Patient data collection requirements vary according to health care setting
vary according to health care setting. A data element you would expect to
be collected in the MDS, but NOT the UHDDS would be? - ✔✔B.
Cognitive Patterns
In the past, Joint Commission standards have focused on promoting the
use of a facility-approved abbreviation list to be used by hospital care
providers. With the advent of the Commission's national patient safety
goals, the focus has shifted to the: - ✔✔C. Use of prohibited or
"dangerous" abbreviations
,©JOSHCLAY 2024/2025. YEAR PUBLISHED, 2024.
Engaging patients and their families in health care decisions is one of the
core objectives for: - ✔✔A. achieving meaningful use of EHRs
A risk manager needs to locate a full report of a patient's fall from his bed,
including witness reports and probable reason for the fall. She would most
likely find this information in the: - ✔✔C. incident report
For continuity of care, ambulatory care providers are more likely than
providers of acute care services to rely on the documentation found in the: -
✔✔D. problem list
Joint Commission does not approve of auto authentication of entries in a
health record. The primary objection to this practice is that: - ✔✔B.
evidence cannot be provided that the physician actually reviewed and
approved each report
As part of a quality improvement study, you have been asked to provide
information on the menstrual history, number of pregnancies, and number
of living children on each OB patient from a stack of old obstetrical records.
The best place in the record to locate this information is the: - ✔✔A.
antepartum record
As a concurrent record reviewer for an acute care facility, you have asked
Dr. Crossman to provide an updated history and physical for one of her
, ©JOSHCLAY 2024/2025. YEAR PUBLISHED, 2024.
recent admissions. Dr. Crossman pages through the medical record to a
copy of an H&P performed in her office a week before admission. You tell
Dr. Crossman: - ✔✔C. the H&P copy is acceptable as long as she
documents any interval changes
You have been asked to identify every reportable case of cancer from the
previous year. A key resource will be the facility's: - ✔✔A. disease index
Joint Commission requires the attending physician to countersign health
record documentation that is entered by: - ✔✔A. interns or medical
students
The minimum length of time for retaining original medical records is
primarily governed by: - ✔✔C. state law
The use of personal signature stamps for authentication of entries in a
paper-based record requires special measures to guard against delegated
use of the stamp. In a completely computerized patient record system,
similar measures might be utilized to govern the use of: - ✔✔D.
electronic signatures
Discharge summary documentation must include: - ✔✔C. significant
findings during hospitalization
