Exam 2: Collecting Health Care Data

"Rule out Congestive Heart Failure versus Cerebrovascular Accident" is an example of which of the following components of medical decision making?

The following statement will be found in the ________ step of medical decision making. "Patient states dizziness and shortness of breath."

Which of the following is NOT a benefit of a problem list?

Describing Data Name Definition Size Type Exarnple FNAME Patient's First Name 15 Characters Alphabetical Jarse LNAME Patient's Last Name 15 Characters Alphabetical Jones HTEL Patient's Home Telephone Nurmber 12 Characters Alpharumnerica 1 973-555-3331 TEMP Patient's Temperature 5 Characters Nurnerical 98.6 -Use the sample data descriptions above to answer the following question. Using 12 alphanumerical characters is one way to capture the patient's home telephone number. List at least one other way to capture that data.

In creating an electronic data collection screen, which of the following is the most important consideration?

Dr. Smith is a physician in general, or family, practice. He and his partner, Dr. Wong, are evaluating the way they organize their paper record documentation. They have a large number of patients, many of whom have multiple, chronic illnesses. The doctors would like to organize their records to make it easier to see what has been done with respect to each patient's illness. As their office manager, what do you recommend?

List and describe at least three different characteristics of data quality.

Explain how a health information technician ensures the quality of the health information database.

SOAP notes are examples of ____ data.

All of the following are considered data sets EXCEPT:

Public health data collected through birth certificates, death certificates, and other data gathering tools are called _______ statistics.

A listing of all fields and their definitions is called a ________.

How does the quantity of health data affect our understanding of what it contains?

Define characters, fields, records, and files. Give two examples of each.

Which of the following data sets is used by acute care facilities?

Medical forms design is an essential task for HIM professionals. What factors need to be considered? Name at least two.

In which step of the medical decision-making process can the following statement be found? "Patient's BP 120/75, rule out hypertension"

Describing Data Name Definition Size Type Exarnple FNAME Patient's First Name 15 Characters Alphabetical Jarse LNAME Patient's Last Name 15 Characters Alphabetical Jones HTEL Patient's Home Telephone Nurmber 12 Characters Alpharumnerica 1 973-555-3331 TEMP Patient's Temperature 5 Characters Nurnerical 98.6 -Use the sample data descriptions above to answer the following question. List and describe two additional fields that would be needed to capture a patient's entire name.

"Chest x-ray to rule out CHF" is an example of which of the following components of medical decision making?

Your facility is using a paper-based record. The HIM department has decided to switch from an integrated record to a completely source-oriented record, postdischarge. You are responsible for training the staff members who assemble the records into the correct order. Which of the following must exist in order to implement this change?