WGU C810 Foundations in Healthcare Data Management

Which form of review is conducted after a patient is discharged from an acute care facility in order to obtain information about trends and patterns of documentation? - Correct Answer-Closed-record review Which guideline should an health information management (HIM) professional follow for documentation of both paper and electronic records? - Correct Answer-Original documents should be maintained in the health record. Which data type is a cardiac catheterization examination note an example of? - Correct Answer-Unstructured data A paragraph in a physician's order specifies information about a patient's discharge. Which type of data is described in this scenario? - Correct Answer-Unstructured A health information manager is responsible for properly destroying records after the retention period has passed. Which principle for information governance is described in this scenario? - Correct Answer-Disposition A chief information officer at a hospital is working to improve data security methodologies within the hospital's electronic health record (EHR). The chief information officer enlists the help of the hospital's health information management (HIM) director to help design and enforce the new data security policies, which include the utilization of a new token system to access the EHR.Which information governance principle is described in this scenario? - Correct Answer-Protection In a healthcare facility that still uses paper records, a physician is requesting a record to complete a discharge summary that is now 28 days past due. The record tracker states that the record has been sent to storage.Which record-keeping principle applies to this scenario? - Correct Answer-Availability What does a stakeholder analysis of a data governance system identify? - Correct Answer-Needs of those interested in the data Which organization requires reporting of medical malpractice payments, federal licensure and certification actions, and adverse clinical privileges actions? - Correct Answer-National Practitioner Data Bank (NPDB) What is the name of the Centers for Medicare and Medicaid Services (CMS) external audit program that works to reduce Medicare improper payments? - Correct Answer-RACs Which assessment do the Conditions of Participation require all home health agencies to electronically report? - Correct Answer-OASIS To which organization must a sentinel event be reported? - Correct Answer-The Joint Commission Which model describes the information that flows to more than one regional clinical data repository (CDR) and requested records sent from one regional authority? - Correct Answer-Federated A local skilled nursing facility (SNF), hospital, and public health agency all participate in a health information exchange (HIE). The data is pushed from their facilities into one repository where they all have access to retrieve data when needed.Which model is described in this scenario? - Correct Answer-Centralized Which quality characteristic describes data that is unaffected when used across all applications and systems? - Correct Answer-Consistency During a storm, the operation of information systems and data preservation are threatened, triggering a disaster protocol.Which disaster recovery planning process step should be taken in this situation? - Correct Answer-Execute the continuity plan An acute care facility is concerned with identity theft and wants to update policies to detect identity theft in day-to-day operations, take steps to prevent the crime, and mitigate its damage. Which prevention program element should the facility update? - Correct Answer-Red Flags Rule Which method of disposal would cause compliance issues for records that have met their required retention? - Correct Answer-Records that are trashed once reaching their retention A hospital's chief executive officer (CEO) notices a spike in complaints about a certain unit and wants to know the average number of patients admitted to that unit in order to monitor staff need. Where should the CEO look for this data? - Correct Answer-Daily census report When an entry is made to a disease registry, an automatic format check ensures the data field for "Present on Admission" (POA) is completed.Which principle of data stewardship is this an example of? - Correct Answer-Establishing controls A health information management (HIM) director is writing a data dictionary for a new disease registry.For which area is this HIM director being a data steward? - Correct Answer-Data definition A report is needed from a disease registry, but patients' names must be de-identified.Which category of key principles and practices applies to this scenario? - Correct Answer-Responsibility of health data steward A patient is being seen by a physician. The patient describes the reason for the visit and the history of present illness in detail. The physician records notes electronically at the point of care. Which technology supports point-of-service documentation for this visit? - Correct Answer-Electronic health record (EHR) What is the best definition of a care path? - Correct Answer-Protocol for the process of care What are the standards related to archiving images? - Correct Answer-Digital Imaging and Communications in Medicine (DICOM) How often are national morbidity data reported? - Correct Answer-Weekly Which reimbursement methodology is typically used for government-sponsored healthcare programs such as Medicare? - Correct Answer-Prospective payment system (PPS) When patients have more than one insurance policy, which process ensures that there is no duplication of benefits paid? - Correct Answer-Coordination of benefits Which exchange methodology uses email pushes? - Correct Answer-DIRECT exchange Which HIE architecture has all data stored in a shared data repository? - Correct Answer-Centralized In which healthcare setting does CMS require specific documentation by the attending physician and an update to the patient's plan of care? - Correct Answer-Home healthcare For which healthcare setting is the patient's history and physical exam a required part of the health record? - Correct Answer-Acute care and behavioral health A report contains evidence of a review of a patient's record, the examination of the patient, pertinent findings, and recommendations. In which type of report would this information be found? - Correct Answer-Consultation Why is a patient's history and physical (H and P) used in an inpatient hospitalization? - Correct Answer-To document surgical findings Regarding continuity of care, which documentation are ambulatory care providers more likely than acute care providers to rely upon? - Correct Answer-Problem list In addition to the typical management processes of planning, organizing, and directing, what is included in the development of a governance program? - Correct Answer-Controlling Which data item would be recorded in an ER record but probably not in an acute care record? - Correct Answer-Time and means of arrival correct Data governance focuses primarily on managing data as it is being created within a healthcare system. What does information governance mainly focus on managing? - Correct Answer-The output of healthcare systems A large healthcare organization holds quarterly meetings of a committee composing its compliance officer, privacy officer, information security officer, chief information officer, and vice president of HIM. These meetings review recent breaches, the need for new policies, and compliance with requirements for employee training and education related to information management. Which generally accepted recordkeeping principle (GARP) is this an example of? - Correct Answer-Accountability What are some examples of discrete, unstructured data? - Correct Answer-Transcribed radiology reports, itemized bills, uniformed billing forms A coder encounters a medical record where a sputum culture indicates bacterial pneumonia, but the diagnosis does not specify the cause. Which criteria does the documentation in the patient's record fail to meet? - Correct Answer-Precision A healthcare professional is examining st