Data Integrity correct answers entails security measures put in place that ensure the data are not altered, modified, or deleted either accidentally or with malicious intent.
assists leadership when analyzing best practices, performance improvement initiatives, or regulation of corrective acti...
Data Integrity correct answers entails security measures put in place that ensure the
data are not altered, modified, or deleted either accidentally or with malicious intent.
assists leadership when analyzing best practices, performance improvement initiatives,
or regulation of corrective actions
ex. patient experiences adverse reaction to a medication. the nurse who administered
the medication accesses the patient's chart and alters the dosage to the correct dosage.
Integrity Measures correct answers ensure every entry in the EHR is a locked, signed
entry or document, that versioning of the documents is permitted and accessible or for
paper records they are written in ink.
Proper Error correct answers correction policies and procedures are in place
Data Correction or Versioning correct answers ensure that the data visible to the reader
are true, accurate and validated
all previous versions should be archived
important that all versions of documents are accessible in event of lawsuit
the most recent locked and signed version is considered the legal record
Editing Document correct answers creates new version
Data Integrity Constraints correct answers conditions in which a field in an EMR is
programmed and how it will store data
ex. date field (numerical characters) MM/DD/YYYY
Legal Value correct answers data integrity condition stating the minimum and maximum
Scenario correct answers MRN field with legal value set 00001 to 99999
Record Archiving correct answers practice of categorizing, boxing, and storing records
for an extended period of time
record retention and archival practices are required by law when securing and storing
medical records
, maintaining uniformity when logging records for archiving is critical to identify the
location of that record later
Data Integrity and Release of Information correct answers instrumental in overall
business practices of healthcare organization and HIM department
without data integrity policies and procedures, strict constraints and training could have
detrimental effects on patient care, placement of educational or community services, or
overall inaccurate decision making based on receiving the incorrect PHI
Reasons Why PHI might be released correct answers -educational
-coordination of care
-legal
-community support
-custody, etc
Length of Stay correct answers difference between the discharge date and the
admission date; assists in analyzing costs for hospital stays
ex: Mary was admitted on Feb 20th and discharged Feb 24 = LOS days
discharge date is not routinely counted because the patient is discharged prior to
midnight; a bed is calculated at midnight
Average Length of Stay (ALOS) correct answers common HIM and healthcare statistic
scenario: ALOS for adult populations whose primary diagnosis is type 1 diabetes. at a
minimum, the admission and discharge dates are needed to calculate the LOS. average
them together to find ALOS. additional elements (ALOS by patient age, gender, unit,
program, diagnosis, or by physician, etc)
Audit correct answers Review or analysis of record to ensure that policies and
procedures are being followed
Audit Sample correct answers how many records will be reviewed
auditing a new initiative should include completion and quality audits to be sure that the
information is present, legible, and reliable.
Patient Census Day (Bed Day) correct answers is the number of beds that a hospital
has for any 24-hour period, whether that bed is occupied or vacant
hospital census is taken at midnight in accordance with CMS regulations
Percentage of Occupancy correct answers percentage of occupied beds against the
total number of licensed beds
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