Questions and Answers
Which data set would the health record technician consult to ensure the system collects all federally required discharge data elements for Medicare and Medicaid inpatients in an acute-care hospital?
Standardizing medical terminology to avoid differences in naming various health conditions and procedures is one purpose of:
Patient care managers use the data documented in the health record to:
This situation reflects a problem in: Mrs. Smith's date of birth is recorded as 3/25/1948, but the audit discovers that the numbers are transposed in reports.
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What clinical report would be the best source to gather daily blood pressure readings for patients diagnosed with hypertension?
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Which of the following is a key characteristic of the problem-oriented health record?
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Which of the following is true regarding the reporting of communicable diseases?
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Study Notes
Health Record Standards and Definitions
- UHDDS: The Uniform Hospital Discharge Data Set ensures collection of all federally mandated discharge data for Medicare and Medicaid inpatient care in acute-care hospitals.
- Vocabulary Standards: Essential for standardizing medical terminology, avoiding discrepancies in naming health conditions and procedures, and ensuring consistent descriptions in health records.
Patient Care Insights
- Patient Care Managers evaluate patterns and trends based on documented data in health records, facilitating improved service delivery in specific areas of health care.
Data Quality Issues
- Data Consistency: Critical for reliable patient data; discrepancies, such as transposed birth dates in records, highlight issues in maintaining consistent information across the health record.
Clinical Data Sources
- Vital Signs Record: The primary source for obtaining blood pressure readings and other vital statistics, crucial for analyzing patients with hypertension over specified periods.
Problem-Oriented Health Records
- Characterized by an itemized list of a patient's past and present health problems, which enhances the relevance of patient information for both care providers and patients.
Reporting Regulations
- Communicable Diseases Reporting: Obligatory reporting of certain diseases is determined by state law, with healthcare facilities required to notify public health departments upon patient diagnosis.
Health Information Management Responsibilities
- The HIM director's initial task in overseeing data content standards for an EHR system involves ensuring that standards are not only identified but also understood and effectively implemented within the organization.
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Description
Test your knowledge on the essential discharge data elements needed for Medicare and Medicaid inpatients. This practice exam covers a variety of questions related to electronic health records (EHR) and health information management in acute-care settings. Improve your understanding of the relevant data sets and regulations.
