Abdelhak et al: Health Information: Management of a Strategic Resource, 2nd edition




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Abdelhak et al: Health Information: Management of a Strategic Resource, 2nd edition

Chapter 3: Data Collection Standards


1. Data uniformity is one characteristic of a health care data set.

A) True

B) False


2. Name a data element comprising socioeconomic data.


3. Name a data element comprising clinical data.


4. Name a data element comprising financial data.


5. All of the following are health care data sets EXCEPT which one?

A) MDS

B) NCDB

C) UADS

D) UHDDS


6. Which is secondary health care data?

A) measles immunization: 3/12/89

B) 23 nosocomial infections

C) KaCl 500 mg daily

D) patient LOS = 3 days


7. Define this quality factor in relation to health care data:

organized data.


8. Define this quality factor in relation to health care data:

timely data.


9. Which is a demographic datum collected in a health information system database?

A) DOB

B) financial guarantor

C) discharge order

D) admission date


10. What data management criterion has been met when the data collected meet the needs and stated goals of the health care organization?

A) data appropriateness

B) data availability

C) data completeness

D) data reasonableness


11. The RAI is used to capture assessment data every 14 days in long-term care.

A) True

B) False


12. Name two categories of data the MDS collects on long-term care inpatients or residents.


13. What prerequisite must data meet in order to be comparable among external users of the data?

A) appropriateness

B) reasonableness

C) timeliness

D) uniformity


Use the following to answer questions 14-22:


Match the abbreviation with its correct descriptor. Not all descriptors may have answers.


A) data set for tracking the mix of patients in managed care

B) comprehensive assessment of a long-term care patient

C) comprehensive data set managed by ASTM

D) data set for hospitals used by federal and state agencies for billing

E) agency that collects vital statistics data

F) database supportive of health care policy and research

G) agency that collects reportable morbidity information of public interest

H) data set for ambulatory care

I) agency that accredits rehabilitation organizations

J) data set for home health care

K) billing instrument for inpatients

L) data set for long-term care


14. UB-92


15. MDS 2.0


16. CARF


17. E 1384


18. NCVHS


19. OASIS


20. UADS


21. RAI


22. UHDDS


23. Each of the following are examples of aggregate data EXCEPT:

A) 120 live births

B) product of conception weighed 1005 gm

C) post-operative infection rate = 1.37%

D) 11,522 inpatient service days


24. The JCAHO collects data for the purpose of accreditation using the Uniform Clinical Data Set (UCDS).

A) True

B) False


25. Data from patient satisfaction surveys are an example of internal data.

A) True

B) False


26. When a health care organization analyzes market trend data, such as anticipated enrollment in managed care plans, they are examining external data.

A) True

B) False


27. The medical staff uses primary and secondary data for peer review.

A) True

B) False


28. Attorneys use primary data to settle malpractice claims.

A) True

B) False


29. Providers of care use clinical data for determining effective utilization of services.

A) True

B) False


30. Administrators of health care organizations use internal and external data for benchmarking.

A) True

B) False


31. Third party payers use primary data for health care reimbursement.

A) True

B) False


32. Distinguish between primary and secondary data.


Use the following to answer question 33:


Fig. 3-1




33. Referring to the discharge summary in Fig. 3-1, identify three general data elements missing from the report which are required by the JCAHO standards. Do not include the fact that the summary was not signed.


34. The abbreviation ANSI represents the _________.


35. The ________ developed the UHDDS.


36. The __________ sets standards for the collection of cancer data by hospitals.


37. The purpose of the _________ organization is to provide guidelines for interfacing health information systems within health care organizations or facilities.


Use the following to answer question 38:


Fig. 3-2








38. Referring to the information in Fig. 3-2, what are the 2 errors on the ADT list?


39. Which data set was developed for capturing primary data on outpatients and clinic patients?

A) Uniform Clinical Data Set

B) Uniform Ambulatory Care Data Set

C) Ambulatory Care Group Case Mix Management System

D) Minimum Data Set


40. One of the primary goals of the United Network of Organ Sharing is:

A) to ensure organs are available for persons who are in need

B) to provide for the distribution of organs

C) to provide governmental control of organs

D) to inform providers of available organs


41. Health care data of particular interest to the administration include:

A) physicians' orders

B) patient address

C) consultations

D) services used


42. The organization that compiles data on osteopathic physician location and type of practice is the:

A) JCAHO

B) NPDB

C) APA

D) AOA


43. Which is an organization that provides a comprehensive package of health care services for a fixed rate?

A) health maintenance organization

B) peer review organization

C) preferred provider organization

D) both a and c


44. The WEDI report focused on:

A) reduction of costs through electronic claims processing

B) educational programs regarding electronic data interchange

C) standards for data content and coding structures

D) vendor interfacing


45. Which registry collects data internationally?

A) cancer

B) implant

C) organ sharing

D) trauma


46. Standards pertaining to the EHR are developed by which organization?

A) ASTM

B) DHHS

C) JCAHO

D) HCFA


47. All of the following are associated with creating standards for the electronic exchange of healthcare data EXCEPT

A) HL7

B) X12N

C) ASTM

D) NPDB


48. Each of the following is a data set EXCEPT

A) UMLS

B) LTS

C) UAS

D) UHDDS


49. Each of the following are general formats of the primary patient record EXCEPT:

A) integrated

B) patient-oriented

C) problem-oriented

D) source-oriented


50. Minimum data sets are available for use in all of the following health care delivery systems EXCEPT:

A) acute care

B) ambulatory care

C) long term care

D) mental health care


51. Which characteristic qualifies the purposes of a data set?

A) comparability

B) compatibility

C) reliability

D) uniformity

E) all of the above


52. The UPIN is used for:

A) sequencing data

B) formatting data

C) event validation

D) identification


53. The UHDDS is a non-segmented data set.

A) True

B) False


54. The U.S. Census Bureau plays an active role in sponsoring, developing and approving data sets in health care.

A) True

B) False


55. An integrated primary patient record is formatted by:

A) date

B) source

C) problem

D) none of the above


56. Health information management control issues in data collection should include:

A) controlling costs

B) identifying all views and forms

C) capturing all the data

D) all of the above


57. All health care data should be collected for an identified purpose for their retrieval and use.

A) True

B) False


58. Each data item should be captured once by an information system for all users that need the data item.

A) True

B) False


59. Which of the following activities is supported by patient data?

A) evaluation of care

B) clinical education

C) financial viability

D) all of the above


60. All of the following are costs associated with data collection EXCEPT

A) data input

B) data management

C) data brokering

D) data transaction time


61. Data stored in paper form are static and lack the advantages of reorganization, manipulation, and integration.

A) True

B) False


62. All patient data stored in a database must contain standardized content to be exchangeable electronically.

A) True

B) False


63. ASTM and the JCAHO are examples of standards development bodies for the content of electronic health records.

A) True

B) False


64. Both ASTM and JCAHO standards are voluntary.

A) True

B) False


65. All standards are validated before adoption by health care organizations.

A) True

B) False


66. What is the nominal title for ASTM Standard E 1384?

A) Standards for Patient Privacy, Confidentiality, and Access

B) Standards for Authentication of Health Information

C) Standards for Content and Structure of the Computer-Based Patient Record

D) none of the above


67. All of the following are characteristics of a voluntary standard, such as an ASTM standard, EXCEPT

A) guide

B) mandate

C) model

D) blueprint


68. Which of the following are advocated by AHIMA to help standardize clinical data?

A) classifications

B) nomenclatures

C) patient record formats

D) all of the above


69. The creation, authentication, and retention of health information is permitted and protected by federal legislation.

A) True

B) False


70. What is included in ASTM Standard E 1384?

A) structure of a CPR

B) entity relationships

C) definitions of data items

D) all of the above


71. A data element is the same as a data item.

A) True

B) False


72. The electronic exchange of detailed patient data elements requires the use of common data definitions.

A) True

B) False


73. When data are complete and accurate they have reliability.

A) True

B) False


74. Data should be collected for a prespecified, identified purpose and user.

A) True

B) False


75. When designing forms and computer views, one should consult regulations and standards in addition to the needs of the user.

A) True

B) False


76. Computer views should guide the data collection and data validation process.

A) True

B) False


77. As with forms identification in a paper-based record, each computer view should be identified in the systems documentation.

A) True

B) False


78. Good forms design divides forms into logical sections by rules.

A) True

B) False


79. Which of the following can electronically facilitate the creation of views for data capture and data display?

A) ASTM

B) DBMS

C) MDS

D) OCR


80. Discuss ASTM E 1384 and its impact on health information systems.


81. Describe three principles of computer view design.


82. Within how many hours, according to the JCAHO, must all verbal orders associated with a potential hazard to the patient be authenticated?

A) 24 hours

B) 48 hours

C) 72 hours

D) within a time frame defined in the medical staff rules and regulations


83. Type I deficiencies, according to the JCAHO, must be resolved before a health care organization can be granted accreditation.

A) True

B) False


84. When reference is made to health care data having integrity, it means that the data are complete and accurate.

A) True

B) False


85. When a patient record is missing one or more authentications, it is incomplete but not delinquent.

A) True

B) False


86. Quantitative analysis of the patient record is the same as deficiency analysis.

A) True

B) False


87. When the legality of data is affirmed, the data have been created, authenticated, stored, and corrected according to law or regulation.

A) True

B) False


88. Report validation is included in qualitative analysis.

A) True

B) False


89. Data have the quality of ___________ when they are recorded at or near the time of the event or observation.


90. You are the HIM Department manager at Rocky Mountain Nursing Home, which has been cited by the state surveyors for lack of receipt of an admission history and physical in a timely manner. This information is extremely important for patient care at the time of transfer to the nursing home and is an important part of the clinical database. It has been difficult for you to receive the transfer information from one hospital in particular, one that is the major referral source for your nursing home. Your administrator requests that you send a letter to the HIM director at the hospital with a copy to the hospital administrator and to himself regarding this problem and seeking their help. Write the letter and address it to: Chris Morgan, RRA, Director of Health Information Services, Rocky Mountain Hospital, 1299 94th Ave., SW, Cougar, WA 98000. The hopital administrator's name is Josephine Anderson and the nursing home administrator is Frank Henderson. Be sure to include enough information so that they understand your requirements and the methods to meet the requirements.


91. You now are Chris Morgan, Director of Health Information Services at Rocky Mountain Hospital. You have received this letter from Rocky Mountain Nursing Home and have received complaints from several other nursing homes and home health agencies that they do not receive transfer information from your hospital in a timely fashion. List or describe procedures you could put into place in your department to resolve this problem.


92. A major source of health care data is obtained at the time of initial interview with the patient/family. Identify problems that can occur at this point regarding data quality, and provide solutions an organization could institute to correct them.


Answer Key


1. A

2. (any one) patient name; address; DOB; next of kin; marital status; occupation

3. (any one) diagnoses; procedures; orders; lab results; treatment; physical findings; medications

4. (any one) principal source of payment; guarantor of payment; address of guarantor

5. B

6. B

7. data are standard and processed in a way in which they can be stored and produced.

8. usable data are available when needed

9. A

10. A

11. B

12. (any two) socioeconomic; financial; clinical data

13. D

14. K

15. L

16. I

17. C

18. E

19. J

20. H

21. B

22. D

23. B

24. B

25. A

26. A

27. A

28. A

29. A

30. A

31. A

32. Primary data refers to original data that results from direct patient care. The patient's health record data are primary. Secondary data are those collected from primary sources and input into a variety of indexes (such as diagnostic and procedure indexes) and registries (such as cancer, trauma, implant, birth defect, etc.)

33. 1. significant findings

2. patient's condition on discharge

3. instructions to patient/family

34. American National Standards Institute

35. U.S. Dept. of Health, Education & Welfare now U.S. Dept. of Health &Human Services or NCVHS

36. American College of Surgeons

37. HL7

38. 1. Nancy Allen-is in bed 303-2 (11:59pm, January 15) and then is listed as admitted on January 16 on the ADT list.

2. Michelle Ramsey-is on the ADT (Discharge section), but not in the Admission Section: discharge entry notes this as an admittance/discharge on the same day.

39. B

40. B

41. D

42. D

43. D

44. A

45. B

46. A

47. D

48. A

49. B

50. D

51. E

52. D

53. A

54. B

55. A

56. D

57. A

58. A

59. D

60. C

61. A

62. A

63. B

64. A

65. A

66. C

67. B

68. D

69. B

70. D

71. A

72. A

73. B

74. A

75. A

76. B

77. A

78. A

79. B

80. ASTM E 1384 is a voluntary standard (guide) for the content and format of a computer-based patient record. It includes data elements and their definitions that are intended to provide the common database essential for the electronic exchange of useful data in a consistent and efficient manner. It consists of 14 segments organized around broad categories including patient, provider, problem, and observation. The standard provides a common vocabulary and structure applicable to all types of health care services interested in developing, purchasing, or implementing CPR systems.

81. (Any three)

(1) Good computer view design should emphasize the needs of users.

(2) Each view should have an identifiable purpose and sequencing of needed data items.

(3) The design should employ standardized terminology, format, and abbreviations.

(4) The design should be compatible with the technology to be employed.

(5) Each view should include appropriate instructions for capturing the data correctly and consistently.

(6) Each design should be kept as simple as possible.

(7) Each view should guide the user easily through data entry, interpretation, and validation.

82. D

83. B

84. A

85. B

86. A

87. A

88. B

89. currency or timeliness

90. (a) Identify the state/federal laws and regulations that require this information and the fact that you have been cited.

(b) Indicate that this information is extremely important for continuation of patient care on the day of arrival at the facility, as well as for ongoing patient care. You are providing follow-up care that was initiated at the hospital. Since the advent of DRG's, hospitals have been discharging patients very quickly, which often means the newly admitted nursing home residents are still very ill. This information is part of the nursing home's database used for those patients.

(c) Regulations allow copies of histories and physicals from transferring hospitals in lieu of a new H&P done by the physician at the nursing home. This helps to avoid unnecessary expense to the patient and/or third party payer and helps to avoid undue discomfort to a patient when he/she does not need to undergo a second, unnecessary physical exam.

(d) If at all possible, a copy of the hospital's discharge summary should be sent along with the history and physical since it provides information on the course of hospital care that is important for nursing home follow-up care.

91. Place priority transcription of histories and physicals and discharge summaries for patients to be transferred to other facilities; provide stat dictation lines. Work with the hospital discharge planner and/or unit coordinators to alert the physician to dictate the discharge summary that day and to notify the HIM Department when a patient is to be transferred in order that the HIM Department personnel can transcribe reports and copy appropriate portions of the record.

Recommend that information be faxed to the nursing home if information cannot be electronically transferred to them or if the record copies are not sent with the patient/family at the time of discharge.

If written consents are required for the transfer of the information, they should be obtained by designated nursing station personnel from the patient before he/she is discharged from the hospital.

92. Language barriers. Patient too physically ill or emotionally upset to answer properly. Family may be too upset, or may not know all the facts, to answer properly. The patient may be in crisis mode, and the physician may have to begin immediate treatment before detailed interviewing. Patient may be too embarrassed to provide the data needed to the provider. The provider may have poor interviewing skills, poor "bedside manner," may be a poor listener, observer, or documenter. Data input devices (e.g., dictating machine, etc.) may not be available at the point-of-service location.

Interview the patient/family again at a later time. Verify documented information with the family. Interviewer should provide assurances of confidentiality to the patient and family. The HIM professional should assess the quality and location of input devices and resolve as appropriate.


Copyright © 2002 Elsevier Science (USA). All Rights Reserved.

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