Health Data Content Standards Exam Questions with Correct Solutions Latest Version 2025 (Rated A+)
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Health Data Content Standards
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Health Data Content Standards
Health Data Content Standards Exam Questions with Correct Solutions Latest Version 2025 (Rated A+)
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 unname...
Health Data Content Standards Exam Questions with Correct Solutions Latest Version 2025 (Rated A+)
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: - Answers 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? -
Answers 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: - Answers C. Use of prohibited or "dangerous"
abbreviations
Engaging patients and their families in health care decisions is one of the core objectives for: - Answers
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: - Answers 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: - Answers 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: - Answers 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: - Answers 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 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: -
Answers 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: - Answers A. disease index
Joint Commission requires the attending physician to countersign health record documentation that is
entered by: - Answers A. interns or medical students
, The minimum length of time for retaining original medical records is primarily governed by: - Answers 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: - Answers D. electronic
signatures
Discharge summary documentation must include: - Answers C. significant findings during hospitalization
The performance of ongoing record review is an important tool in ensuring data quality. These reviews
evaluate: - Answers D. the overall quality of documentation in the record
Ultimate responsibility for the quality of completion of entries in patient health records belongs to the: -
Answers B. attending physician
The federally mandated resident assessment instrument used in long-term care facilities consists of
three basic components, including the new care area assessment, utilization guidelines, and the: -
Answers B. MDS
The foundation for communicating all patient care goals in long-term care settings is the: - Answers C.
interdisciplinary plan of care
As the Director of a Health Information Technology Program, your community college has been selected
to participate in the workforce development of electronic health record specialists as outlined by ARRA
and HITECH. In order to keep abreast of changes in this program, you will need to regularly access the
Web site of this governmental agency. - Answers A. ONC
As part of the Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now
required to use a preoperative verification process to confirm the patient's true identity, and to confirm
that necessary documents such as x-rays or medical records are available. They must also develop and
use a process for: - Answers C. marking the surgical site
In preparing your facility for initial accreditation by the Joint Commission, you are trying to improve the
process of ongoing record review. All health record reviews are presently performed by a team of HIM
department personnel. The committee meets quarterly and reports to a Quality Management
Committee. In reviewing Joint Commission standards your first recommended change is to: - Answers D.
provide record reviews to be performed by an interdisciplinary team of care providers
According to the Joint Commission's National Patient Safety Goals, which of the following abbreviations
would most likely be prohibited? - Answers D. .4 mg Lasix
A qualitative review of a health record reveals that the history and physical for a patient admitted on
June 26 was performed on June 30 and transcribed on July 1. Which of the following statements
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