answers
A basic premise of sound information governance is that within each organization,
a senior leader is formally designated as responsible for the overall program
development and its implementation. Aspirus Healthcare has thereby committed
that our CIO will be accountable for ensuring the information governance
program aligns with and supports the goals and strategies of the organization.
The CIO is also accountable for ensuring appropriate resources are allocated to
support the program. Ans✓✓✓ Accountabilitiy
A coder came across a medical record where a sputum culture indicated bacterial
pneumonia, but the diagnosis did not indicate the cause of the pneumonia.
Documentation in the patient's record failed to meet which one of the following
criteria: Ans✓✓✓ precision
A coding supervisor audits coded records to ensure the codes reflect the actual
documentation in the health record. This code auditing process addresses the
data quality element of: Ans✓✓✓ Accuracy
a number of key elements for your facility's computerized patient record are still
input by clerical staff from handwritten data entry sheets. you are concerned
about the transfer of data. if the vital signs stored in the database are not what
were originally recorded, the impact on patient care could be severe. you are
concerned about the Ans✓✓✓ validity of the data
A patient has been admitted to the hospital. The health record number is used to
identify where the patient's data is stored in the health information exchange.
This information is found using: Ans✓✓✓ record locator service
, A physician has decided to retire from her practice and has decided to sell the
practice to a local hospital. Due to the transfer of the medical records to the new
hospital, we have to follow the record-keeping principle of Ans✓✓✓ Disposition
A physician's office has requested PHI for continued care. The release of
information clerk wants to limit the information provided because of the
minimum necessary rule. What should the supervisor tell the clerk? Ans✓✓✓
Patient care is an exception to the minimum necessary rule, so process the
request as written.
A qualitative analysis of OV records reveals a pattern of inconsistent data entered
when comparing documentation of the same data elements captured on both the
prenatal form and labor and delivery form. The characteristic of data quality that
is being compromised in this case is data. Ans✓✓✓ reliability
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 regarding the history and physical is true in
this situation? Completion and charting of the H&P indicated Ans✓✓✓
noncompliance with Joint Commission standards
A research request has been received by the HIM department from the Quality
Improvement Committee. The Committee plans to review the records of all
patients who were admitted with CHF in the month of January 2019. Identify the
index that would be the best source for the location of the necessary records.
Ans✓✓✓ disease index
All children will be entered into which of the following registries at birth, and thus
will continue to be monitored by the registry in their geographic area? Ans✓✓✓
Immunization Registry