C810 Foundations in Healthcare Data Management
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Free C810 Foundations in Healthcare Data Management Questions
1. Which of the following is not a type of unstructured data?
- Cardiac catheterization examinations
- Signed consent forms
- Lab orders
- Handwritten notes
Explanation
Lab orders are not considered unstructured data because they are typically captured in a structured format with predefined fields, codes, and standardized input in an electronic health record system. Unstructured data, in contrast, includes information that is narrative or free-text in nature, such as handwritten notes, signed consent forms, or detailed examination reports, which do not follow a rigid format and may require interpretation for analysis. Structured data like lab orders allows for easier storage, retrieval, and analysis.
2. A health information management (HIM) director is auditing physician documentation and finds that 3% of the discharge summaries from the last six months were completed more than 30 days past the patient. Which data quality standard is an area of concern in this scenario?
- Timeliness
- Accuracy
- Comprehensiveness
- Precision
Explanation
In this scenario, the HIM director is concerned with the delay in completing discharge summaries, which directly relates to the timeliness of the data. Timeliness refers to whether data is recorded and available within a timeframe that allows it to be useful for patient care, reporting, and decision-making. Completing discharge summaries more than 30 days late indicates that the documentation is not meeting the required time standards, potentially affecting patient care continuity, billing, and reporting accuracy. This makes timeliness the primary data quality standard of concern.
3. The National Practitioner Data Bank (NPDB) provides a database of:
- facilities in which the practitioner has practiced.
- awards of excellence granted to the practitioner.
- records of malpractice award amounts to patients.
- patient reviews of quality of care delivered.
Explanation
The National Practitioner Data Bank (NPDB) maintains a database that includes records of malpractice payments and certain adverse actions taken against healthcare practitioners. It is designed to support efforts to improve healthcare quality and protect patients by allowing hospitals, licensing boards, and other entities to access information about a practitioner’s history of malpractice or disciplinary actions. The NPDB does not track awards, patient reviews, or the facilities in which a practitioner has worked.
4. What should the HIM professional perform first to identify the components of the legal health record?
- develop a list of all data elements referencing patients that are included in both paper and electronic systems in the practices
- develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records
- perform a quality check on all health record systems in the practice
- develop a listing and categorize all information requests for health information over the past 2 years
Explanation
The first step in identifying the components of the legal health record is to develop a list of all data elements referencing patients that are included in both paper and electronic systems. This allows the HIM professional to establish which pieces of information are considered part of the official legal record and ensures that both electronic and paper-based data are accounted for. This foundational step must occur before reviewing statutes, performing quality checks, or analyzing past information requests, as understanding the contents of the legal health record is critical for compliance, release, and management purposes.
5. The main advantage of health information networks (HINs) and health information exchange (HIE) is that providers treating a patient
- Receive guidance on the best course of treatment for her.
- Have access to all of her medical records and health information
- Can find out what services are and are not covered by her health plan
Explanation
The primary advantage of health information networks (HINs) and health information exchanges (HIEs) is that they provide providers with access to a patient’s comprehensive medical records and health information across different healthcare organizations. This access allows for better-informed clinical decisions, improved care coordination, and reduced duplication of tests or procedures. While HIEs can support clinical decision-making, they do not directly provide guidance on treatment choices or insurance coverage specifics; their main benefit is the availability and interoperability of medical information.
6. A regional healthcare organization is tasked with gathering data on patient admissions across multiple facilities in the area. Which standardized database would be most appropriate for this organization to utilize for their data collection?
- National Inpatient Sample (NIS)
- Healthcare Cost and Utilization Project (HCUP)
- Uniform Hospital Discharge Data Set (UHDDS)
- Patient Safety Organization (PSO)
Explanation
The Healthcare Cost and Utilization Project (HCUP) is the most appropriate database for collecting standardized data on patient admissions across multiple facilities. HCUP provides a set of national and state-level databases that include uniform hospital discharge data, allowing regional organizations to analyze utilization, outcomes, and trends across hospitals. While the National Inpatient Sample (NIS) is a component of HCUP and useful for national-level estimates, HCUP as a whole is designed for broader and standardized data collection. The UHDDS defines data elements for reporting but is not a database itself, and PSOs focus primarily on patient safety events rather than comprehensive admission data.
7. Which assessment do the Conditions of Participation require all home health agencies to electronically report?
- OASIS
- HIS
- MDS
- RAI
Explanation
Home health agencies are required to electronically report the Outcome and Assessment Information Set (OASIS) under the Conditions of Participation. OASIS collects standardized data on patient health status, functional abilities, and outcomes, and is used for quality monitoring, payment, and regulatory compliance. The Minimum Data Set (MDS) and Resident Assessment Instrument (RAI) apply to long-term care settings, while HIS refers to a general Health Information System. OASIS ensures consistent reporting and supports patient care planning and evaluation in home health agencies.
8. According to Medicare Conditions of Participation, a history and physical must be completed no more than __________ days before or __________ hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services.
- 10, 48
- 14, 24
- 30, 24
- 30, 48
Explanation
Medicare Conditions of Participation require that a patient’s history and physical (H&P) be completed no more than 30 days before admission or registration and within 24 hours after admission, but prior to surgery or any procedure requiring anesthesia. This ensures that the patient’s medical status is current and any changes in condition are accounted for before high-risk procedures, which is critical for patient safety and regulatory compliance. The 30-day window before admission and 24-hour window after admission are the standard limits outlined by Medicare.
9. An HIM professional is tasked with ensuring that patient data is accurately reported to the state health department for public health surveillance. This process is crucial for tracking disease outbreaks and health trends. Which principle of data stewardship is being applied in this scenario?
- Data quality
- Transparency
- Compliance
- Data integrity
Explanation
The principle being applied here is data quality. Data quality refers to the accuracy, completeness, and reliability of data, which is essential for public health reporting. Ensuring that patient data is correctly reported allows health authorities to monitor disease outbreaks, track trends, and make informed decisions regarding population health interventions. While transparency, compliance, and data integrity are also important principles of data stewardship, the focus in this scenario is specifically on the accuracy and correctness of the data being reported.
10. Which information governance principle for healthcare stipulates that documentation related to an organization's IG initiatives be available to its workforce and other appropriate interested parties?
- Accountability
- Compliance
- Integrity
- Transparency
Explanation
This describes the principle of transparency. Transparency in information governance requires that all documentation, processes, and activities related to IG initiatives be open, accessible, and verifiable to the organization’s workforce and other relevant stakeholders. This ensures that the IG framework is understood, trusted, and auditable. Accountability focuses on responsibility for actions, compliance ensures adherence to laws and regulations, and integrity ensures accuracy and reliability of data, but the principle specifically emphasizing open documentation is transparency.
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