C810 Foundations in Healthcare Data Management - Set 1 - Part 1

Correct Answer: Timeliness

Timeliness is correct because discharge summaries must be completed within thirty days, and delays violate this critical time-sensitive requirement for documentation.
Option a is incorrect because accuracy relates to error-free data, not the timing of when documentation is completed in the patient record.
Option b is incorrect because granularity refers to the level of detail in data that cannot be further subdivided into smaller components.
Option d is incorrect because consistency involves data being uniform across different systems, not meeting specific deadline requirements for documentation.

Correct Answer: Protection

Protection is correct because implementing authentication and encryption directly addresses data security concerns and prevents unauthorized access to patient information systems.
Option a is incorrect because transparency involves open communication and documentation of processes, not implementing technical security measures for data systems.
Option c is incorrect because disposition relates to the proper destruction or storage of records after their retention period has expired.
Option d is incorrect because retention concerns how long records are kept, not the security measures used to protect them.

Correct Answer: Availability

Availability is violated because medical records must be accessible when needed for patient care, and improper storage prevents timely access.
Option b is incorrect because compliance relates to following laws and regulations, not the physical accessibility of medical records for care.
Option c is incorrect because integrity concerns data accuracy and authenticity, not whether records can be retrieved when needed for treatment.
Option d is incorrect because accountability involves assigning responsibility for governance oversight, not the accessibility of patient records for providers.

Correct Answer: MDS

MDS (Minimum Data Set) is the required assessment tool for nursing homes to document activities of daily living and meet federal requirements.
Option a is incorrect because OASIS is used for home health agencies to assess adult patients, not for nursing home resident assessments.
Option b is incorrect because UHDDS is the Uniform Hospital Discharge Data Set used for acute care hospitals, not long-term care facilities.
Option d is incorrect because HEDIS measures managed care plan quality, not individual patient assessments in nursing home settings specifically.

Correct Answer: Consistency

Consistency is the issue because patient names must be uniform across all systems to prevent errors and ensure safe care delivery.
Option a is incorrect because currency relates to having the most up-to-date information, not uniformity of data across different systems.
Option c is incorrect because granularity refers to the level of detail that cannot be further subdivided, not data uniformity issues.
Option d is incorrect because precision relates to numerical measurements and their closeness to actual values, not name spelling variations.

Correct Answer: EHR

Electronic Health Record (EHR) systems enable providers to document patient encounters in real-time at the point of care delivery.
Option a is incorrect because HIE (Health Information Exchange) facilitates sharing records between organizations, not point-of-care documentation within one facility.
Option c is incorrect because PHR (Personal Health Record) is maintained by patients themselves, not used by physicians for clinical documentation.
Option d is incorrect because CPOE (Computerized Provider Order Entry) is specifically for entering orders, not comprehensive encounter documentation at bedside.

Correct Answer: Contingency Plan

A contingency plan provides procedures for maintaining operations during emergencies like natural disasters when normal systems fail or become unavailable.
Option a is incorrect because the Red Flags Plan specifically addresses identity theft prevention, not emergency response procedures for natural disasters.
Option c is incorrect because a retention plan determines how long records are kept, not how to respond during emergency situations.
Option d is incorrect because a compliance plan ensures adherence to regulations, not specific procedures for disaster response and recovery.

Correct Answer: Disease index

The disease index organizes cases by diagnosis codes, allowing efficient retrieval of all diabetes patients regardless of treating physician.
Option b is incorrect because the operation index lists surgical procedures, not medical diagnoses like diabetes that require non-surgical treatment approaches.
Option c is incorrect because while physician index shows cases by doctor, it wouldn't efficiently identify only diabetes cases among all patients.
Option d is incorrect because the master patient index contains demographic information for patient identification, not clinical diagnosis data for retrieval.

Correct Answer: Centralized model

The centralized model uses one shared data repository where all participating organizations store and access patient information collectively.
Option a is incorrect because the federated model keeps data at individual organizations with a record locator service, not central storage.
Option b is incorrect because the hybrid model combines elements of both centralized and decentralized approaches, not purely central storage.
Option d is incorrect because the decentralized model maintains data at separate locations without a central repository for all participants.

Correct Answer: Thirty days

Discharge summaries must be completed within thirty days after patient discharge according to CMS and Joint Commission requirements.
Option a is incorrect because seven days is too short a timeframe and not the standard requirement for discharge summary completion.
Option b is incorrect because fourteen days, while reasonable, is not the established regulatory timeframe for discharge summary documentation.
Option d is incorrect because sixty days exceeds the required timeframe and would result in non-compliance with documentation standards.

Correct Answer: Keep original entry

Keeping the original entry maintains the legal integrity of the record while allowing proper correction with appropriate annotation and authentication.
Option a is incorrect because erasing destroys the original documentation, which violates legal requirements for maintaining complete medical record history.
Option b is incorrect because blacking out information makes the original entry unreadable and destroys the audit trail of changes.
Option d is incorrect because removing pages from medical records is illegal and destroys the continuity of patient care documentation.

Correct Answer: Closed-record review

Closed-record review occurs retrospectively after patient discharge, allowing comprehensive analysis of documentation patterns and quality issues across cases.
Option a is incorrect because concurrent review happens during the patient's stay while they are still receiving active treatment in facility.
Option b is incorrect because prospective review occurs before services are provided, typically for authorization or planning purposes, not documentation.
Option c is incorrect because open-record review happens while the patient is still in the facility receiving care, not after discharge.

Correct Answer: Comprehensiveness

Comprehensiveness is compromised because all required data elements, including arrival times, must be present for complete emergency documentation.
Option a is incorrect because relevancy concerns whether data is useful for its purpose, and arrival times are always relevant data.
Option b is incorrect because accuracy relates to error-free data, not missing data elements that should be included in records.
Option d is incorrect because definition involves clear meanings for data elements, not whether required elements are actually documented properly.

Correct Answer: Accountability

Accountability is established by requiring senior leadership oversight and approval, ensuring clear responsibility for data governance decisions throughout organization.
Option b is incorrect because transparency involves open communication about processes, not establishing leadership approval structures for governance decisions specifically.
Option c is incorrect because integrity relates to data accuracy and authenticity, not the organizational structure for governance decision-making.
Option d is incorrect because availability concerns timely access to information when needed, not leadership accountability for governance oversight.

Correct Answer: MAR

The Medication Administration Record (MAR) is the specific tool designed for documenting all medication deliveries including required administration details.
Option a is incorrect because progress notes document overall patient condition and response, not specific medication administration details and times.
Option b is incorrect because nursing flowsheets track vital signs and assessments, not the specific details of medication administration events.
Option d is incorrect because treatment records document procedures and therapies, not the specific medication doses and administration times required.

Correct Answer: Twenty-four hours

The full operative report must be completed within twenty-four hours after surgery according to regulatory requirements and standards.
Option a is incorrect because two hours is the requirement for a brief operative note, not the complete operative report documentation.
Option b is incorrect because twelve hours is not the established timeframe and would be insufficient for comprehensive operative documentation.
Option d is incorrect because forty-eight hours exceeds the required timeframe and would result in non-compliance with documentation standards.

Correct Answer: Communication enhancement

Secure messaging enhances patient-provider communication by enabling direct, protected exchanges about health concerns between scheduled visits and appointments.
Option a is incorrect because billing access relates to financial transactions and payment features, not clinical communication between patients and providers.
Option b is incorrect because scheduling convenience involves appointment booking features, not ongoing communication about medical concerns between visits specifically.
Option d is incorrect because record storage relates to maintaining health information, not facilitating active communication between patients and providers.

Correct Answer: Twenty-four hours

CMS requires the history and physical to be documented within twenty-four hours after admission to ensure timely assessment.
Option a is incorrect because twelve hours is more restrictive than required and not the established CMS standard for documentation.
Option c is incorrect because forty-eight hours exceeds the CMS requirement and would result in non-compliance with federal regulations.
Option d is incorrect because seventy-two hours is far beyond the required timeframe for completing admission history and physical documentation.

Correct Answer: Definition

Clear definitions must be established so all departments understand and calculate length of stay consistently across the organization.
Option b is incorrect because currency relates to having current, up-to-date information, not standardizing terminology definitions across departments effectively.
Option c is incorrect because precision involves numerical accuracy and measurements, not establishing common definitions for organizational terms and metrics.
Option d is incorrect because granularity refers to the level of detail in data, not standardizing terminology definitions across departments.

Correct Answer: Disaster Recovery Plan

The Disaster Recovery Plan specifically details procedures for relocating and restoring information systems to alternate sites during emergencies.
Option b is incorrect because Emergency Mode Plans focus on maintaining operations during emergencies, not specifically relocating technology systems to alternate sites.
Option c is incorrect because Privacy Plans address protecting patient information confidentiality, not disaster response procedures for system relocation specifically.
Option d is incorrect because Security Plans focus on preventing unauthorized access, not procedures for relocating systems during disaster events.