WGU D033 Chapter 2 Questions and Answers Graded A+

WGU D033 Chapter 2 Questions and Answers Graded A+ All information must be timely, accurate, and complete Raw Data data that is not organized Information when data is organized and presented to produce meaning Primary data sources :come directly from the original source, :health record is also considered to be a primary source of data. :Highest quality of data Secondary Data Source Data derived from the primary data sources, such as the health record. Secondary data sources include indices, registries, and other databases. Data capture The process of recording healthcare-related data in a health record system or clinical database Data fields can contribute to data quality by limiting the number of choices, by limiting the appropriate entries, and further specifying the data required. Hot Spot Is a type of help message that is triggered when the cursor is placed on top of a data field. It provides an explanation for that data field and what data are needed. Unstructured data fields Data elements that allow for free text entry, which means that the user can type in any data that he or she chooses. Example: text box Structured data fields guide the user during the data entry process, limiting what a user can enter into the field. Example: drop down boxes, certain formats Drop-down menus Structured data that save time because the entire data field item does not have to be typed in the data field. They improve consistency because everyone enters data the same way. Check box type of data field that displays a comprehensive list of approved answers for the data element. Multiple choices. Radio Buttons a type of data field that also identifies a comprehensive list of choices, much like the check box. The difference is that the user can choose only one of the options. Example: Male or Female Numeric Field allows for the entry of numbers. The number of characters and range can be controlled through the data dictionary. It could control the format, such as decimal points and currency. The values in the numeric fields must be able to be added and subtracted, as with age, weight, and so forth. Date Field allows for the entry of valid dates. "Valid" does not mean that the date is correct but rather means that an invalid date (for example, February 30) cannot be entered. Time Field allows for the entry of valid times. It would prevent 26 hours in a day or 70 minutes in an hour. This does not mean that the time is correct but rather means an invalid time cannot be entered. Autonumbering means that the Information System assigns a number in numeric order. This type of field is used for the health record number and the patient account number. For example, the health record numbers would be assigned in numeric order, such as 12-34-56, 12-34-57, and 12-34-58. Template-based data entry A cross between free text and structured data entry. The user is able to pick and choose data that are entered frequently, thus requiring the entry of data that change from patient to patient. It assists the healthcare provider by providing direction in what is to be documented Speech recognition Also known as voice recognition, a technology that translates speech to text. The text must be edited, as speech recognition software may misunderstand words and therefore translate speech into text incorrectly front-end speech recognition (FESR) A speech recognition technology in which the physician or the dictator is the editor of the document that is dictated back-end speech recognition (BESR) A speech recognition technology in which the physician dictates in the traditional manner and an editor listens to the audio and reviews the document created Natural language processing is the technology that converts human language (structured or unstructured) into data that can be translated then manipulated by computer systems. Example:computer-assisted coding Data integrity the extent to which healthcare data are complete, accurate, consistent, and timely. Data quality the reliability and effectiveness of data for its intended uses in operations, decision making, and planning. Required Field is a preset field in which data must be entered before the Information System will allow the user to proceed. Edit Check A standard feature in many applications' data entry and data collection software packages. Edit checks are preprogrammed definitions of each data field set up within the application 1. Which of the following is a data integrity tool? a. Cloning copy/paste b. Natural language processing c. Speech recognition d. Required field d. Data integrity tools include edit checks and required fields. 2. Within an IS, which tool can be accessed by the user to get more information about the data field? a. Help screen b. Edit check c. Hot spot d. Automatic save c. Hot spots provide additional information about the data element. 3. Identify the field type that is BEST for entering gender. a. Drop-down box b. Check box c. Radio buttons d. Text box c. Radio buttons are good for a small number of entry choices such as with gender. 4. Identify the primary data source. a. Data set b. Health record c. Registry d. Index b. Health records are a primary data source. 5. Identify the BEST field type for service. a. Drop-down box b. Check box c. Radio button d. Text box a. Drop down boxes are good to limit entries but allows a number of options from which to choose. Data quality management The business processes that ensure the integrity of an organization's data during collection, application (including aggregation), warehousing, and analysis Collection in data quality management refers to the way that data elements are gathered Application in data quality management is the reason for collecting the data. Warehousing in data quality management involves the methods used to store the data. Processes and systems used to archive data. Analysis in data quality management entails converting data into meaningful information AHIMA Data Quality Management Model displays the components of data quality management and the 10 characteristics of data quality. Data accessibility means that data items are easily obtainable by authorized users. accessible to multiple users at the same time Data Accuracy Data that are free of identifiable errors Quantitative analysis is a review of the health record to determine its completeness and accuracy. Mean all there. Qualitative analysis is a review of the health record to ensure that standards are met and to determine the adequacy of entries documenting the quality of care. Means all filled out. Data Comprehensiveness The patient's health record must be complete and all required data must be included. Physician advisor A hired staff by the healthcare facility to act as a liaison between the HIM or others and the patient's physician Peer review a review by like professionals, or peers, established according to an organization's medical staff bylaws, organizational policy and procedure, or the requirements of state law. The peer review system allows medical professionals to candidly critique and criticize the work of their colleagues without fear of reprisal, as the feedback comes from the committee, not a specific individual. Data Consistency Ensures that like data are the same on each document or computer screen. Example:the date of birth is entered once and is displayed on multiple screens. Data Currency Ensures that data are up to date Data Definition is the specific meaning of a healthcare-related data element. Defining each data element provides the foundation that allows everyone to interpret and collect the data in the same way. Data Granularity The level of detail at which the attributes and values of healthcare data are defined Data Precision Ensures that there is justification for the need to collect the data, such as for patient care, data analysis, billing, and other operational tasks. Data Relevancy Extent to which healthcare-related data are useful for the purposes for which they were collected Data Timeliness Data should be recorded in an appropriate period of time after the event and should be available to the user when needed Data Cleansing The process of checking internal consistency and duplication as well as identifying outliers and missing data. In other words, it means looking for errors or problems with the data, such as duplicate patients Data Mapping Allows for connections between two systems Authorship The origination or creation of recorded information attributed to a specific individual or entity acting at a particular time. Example: electronic signature, login and password Version control The process whereby a healthcare facility ensures that only the most current version of a patient's health record is available for viewing, updating, and so forth Data quality measure Mechanism to assign a quantitative figure to quality of care by comparison to a criterion. Quality measurements typically focus on structures or processes of care that have a demonstrated relationship to positive health outcomes, Example: reduce CAUTI's Data quality measure Part 2 These are used to compare actual patient information to a standard created by an accreditation organization, government agency, or other group to determine the quality of care provided. The data can be aggregated (compiled) and be used to compare healthcare facilities against state or national scores. 1. The identification of the individual who recorded a progress note in the health record is known as ____________. a. Edit check b. Data integrity c. Version control d. Authorship D. Authorship 2. Checking for missing information and outliers is known as ____________. a. Edit check b. Qualitative analysis c. Data cleansing d. Quantitative analysis c. Data cleansing 3. Documentation integrity issues includes ____________. a. Amendments b. Data precision c. Edit check d. Data capture a. Amendments 4. Which characteristic of data quality addresses the level of detail of the data collected? a. Data relevancy b. Data precision c. Data accuracy d. Data granularity d. Data granularity 5. Which attribute of data quality addresses availability of the data collected? a. Data relevancy b. Data consistency c. Data accessibility d. Data granularity c. Data accessibility 1. Identify the type of data field that is most appropriate for the health record number. a. Numeric field b. Autonumbering field c. Text box field d. Radio button field b. Autonumbering field 2. What is the benefit of front-end speech recognition? a. It does not impact the physician. b. The document is available immediately upon completion of the dictation. c. It speeds availability of the document. d. It eliminates data quality issues. c. It speeds availability of the document. 3. A missing document would fall under what type of data quality characteristic? a. Comprehensiveness b. Accuracy c. Consistency d. Definition a. Comprehensiveness 4. What data quality characteristic ensures that data support the reason for the collection of the data? a. Precision b. Currency c. Constancy d. Definition a. Precision 5. The fact that there is missing data would be identified in _________. a. Authorship b. Data analysis c. Data mapping d. Data cleansing b. Data analysis 6. The identification of who documented a note in the health record is known as _________. a. Patient identification b. Authorship c. Authentication d. Validation b. Authorship 7. Identify the statement that is true about amending a health record. a. Anyone should be able to alter the health record at any time. b. The author of an entry should be able to alter the health record at any time. c. Any documentation deleted should be retrievable if needed. d. Health records cannot be amended. c. Any documentation deleted should be retrievable if needed. 8. Ensuring that only the most recent report is available for viewing is known as ____________. a. Documentation integrity b. Authorship c. Validation d. Version control d. Version control 9. Edit checks ensure that ____________. a. The format is appropriate for the data element b. The data entered is accurate for that patient c. The health record is complete d. The data entered is at the level appropriate for the situation a. The format is appropriate for the data element 10. Qualitative analysis reviews the quality of ____________. a. Forms in the health record b. Screen design c. Documentation in the health record d. The data dictionary c. Documentation in the health record