A core data set developed by ASTM to communicate a patient's past and current health information as
the patient transitions from one care setting to another iscorrect answerContinuity of Care Record
A critical early step in designing an EHR is to develop a(n) ___________ in which the characteristics of
each data element are definedcorrect answerData dictionary
A health information technician is responsible for designing a data collection form to collect data on
patients in an acute-care hospital. The first resource that she should use is:correct answerUHDDS
A healthcare enterprise wants to analyze data from multiple computer systems across the organization
to determine trends in patient care services. Which of the following would be the best application to
perform this function?correct answerDatabase
* Data warehouse* CORRECT ANSWER
Spreadsheet
WAN
A hospital is concerned about the difficulty in retrieving health records for patient care and legal
purposes. Some of its data are stored electronically while the remainder are stored on paper. The
hospital knows it will be several years before it will be able to implement an entire EHR system and go
paperless. Given this information, which of the following would be the best solution for the hospital to
ensure that all of the data for a patient data are retrieved when needed?
Answer
Continue with current system
Implement a document scanning system for storage of the paper record
Implement a microfilm system for storage and retrieval of the paper records
Implement a document scanning system for the paper records and interface data created in the current
EHR with the document scanning system.correct answerImplement a document scanning system for the
paper records and interface data created in the current EHR with the document scanning system.
A notation for a diabetic patient in a physician progress note reads: "Occasionally gets hungry. No insulin
reactions. Says she is following her diabetic diet." In which part of a problem-oriented health records
progress note would this be written?correct answerSubjective
A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood
pressure adequately controlled." In which part of a problem oriented health record progress note would
this be written?correct answerAssessment
A nurse is responsible for which of the following types of acute-care documentation?correct
answerMedication record