C810 Foundations in Healthcare Data Management - Set 2 - Part 1

Correct Answer: Implied consent

Implied consent occurs when patients demonstrate agreement through their actions, like cooperating with treatment, without providing explicit written or verbal consent.
Option a is incorrect because informed consent requires detailed explanation of procedures, risks, and benefits with documented patient understanding before treatment begins.
Option c is incorrect because express consent involves explicit verbal or written agreement, not consent demonstrated through cooperative actions without documentation.
Option d is incorrect because written consent requires signed documentation, not agreement shown through patient cooperation with emergency treatment procedures.

Correct Answer: Protection

Protection principle requires implementing security measures like passwords and screen locks to prevent unauthorized access to patient information.
Option a is incorrect because disposition involves proper destruction of records after retention periods, not technical security measures for system access.
Option b is incorrect because retention determines how long records are kept, not the security controls protecting them from unauthorized access.
Option d is incorrect because transparency involves documenting and communicating processes openly, not implementing technical security safeguards for information systems.

Correct Answer: Accessibility

Accessibility is compromised when needed information cannot be retrieved timely, preventing billing staff from completing required claim submissions.
Option b is incorrect because currency relates to having current information, not the ability to retrieve existing charge data when needed.
Option c is incorrect because definition involves clear meanings for data elements, not problems accessing charge information for billing purposes.
Option d is incorrect because precision relates to numerical accuracy in measurements, not the ability to locate and retrieve billing information.

Correct Answer: Transparency

Transparency involves openly sharing information about documentation compliance, allowing medical staff to understand performance metrics and improvement needs.
Option b is incorrect because protection relates to security measures preventing unauthorized access, not reporting compliance metrics to medical staff members.
Option c is incorrect because disposition involves proper record destruction after retention periods, not reporting documentation completion statistics to physicians.
Option d is incorrect because retention determines record keeping timeframes, not the open communication of compliance metrics during staff meetings.

Correct Answer: MDS

Minimum Data Set (MDS) is the federally mandated assessment tool for nursing homes to document resident conditions and care needs.
Option a is incorrect because OASIS is used by home health agencies for patient assessments, not nursing home resident evaluations specifically.
Option c is incorrect because UHDDS collects hospital discharge data for acute care facilities, not long-term care resident assessments comprehensively.
Option d is incorrect because HEDIS measures managed care plan quality performance, not individual nursing home resident assessments for reimbursement.

Correct Answer: Consistency

Consistency ensures allergy information is documented uniformly across all systems, preventing dangerous discrepancies that could compromise patient safety.
Option a is incorrect because granularity refers to the level of detail in data, not uniformity of documentation across different systems.
Option c is incorrect because currency involves having the most recent information, not ensuring uniform documentation across departmental systems specifically.
Option d is incorrect because precision relates to numerical accuracy, not the uniformity of allergy documentation across multiple system platforms.

Correct Answer: Unstructured data

Unstructured data includes narrative text from dictation and transcription that lacks predefined formats or structured data fields completely.
Option a is incorrect because structured data uses templates and defined fields, not free-text narrative from transcribed physician dictation notes.
Option b is incorrect because coded data uses classification systems like ICD-10, not narrative text from transcribed operative dictations specifically.
Option d is incorrect because discrete data consists of separate trackable elements, not continuous narrative text from transcribed surgical reports.

Correct Answer: Data definition

Data definition stewardship involves establishing clear, standardized meanings for terms and metrics used throughout the healthcare organization consistently.
Option a is incorrect because access control determines who can view or modify data, not establishing standardized definitions for metrics.
Option c is incorrect because security management protects data from breaches, not standardizing terminology definitions for consistent organizational reporting specifically.
Option d is incorrect because quality assurance verifies data accuracy, not establishing standardized definitions for metrics across the organization systematically.

Correct Answer: Terminal-digit filing

Terminal-digit filing divides numbers into pairs, organizing records by final digits to distribute files evenly throughout storage areas.
Option a is incorrect because serial numbering assigns sequential numbers without dividing them into pairs for organizational filing purposes specifically.
Option b is incorrect because unit numbering assigns one permanent number per patient, not a specific filing methodology using paired digits.
Option d is incorrect because alphabetical filing uses patient names, not numerical systems divided into pairs for record organization purposes.

Correct Answer: Standardizing definitions

Standardizing definitions establishes approved abbreviations and terminology, ensuring consistent documentation of medical conditions across all providers organizationally.
Option a is incorrect because implementing timelines addresses when documentation occurs, not standardizing medical abbreviations and terminology used by physicians.
Option c is incorrect because increasing accessibility improves record availability, not standardizing abbreviation usage in physician documentation across departments.
Option d is incorrect because improving precision enhances numerical accuracy, not standardizing medical abbreviations and terminology in clinical documentation specifically.

Correct Answer: Disaster recovery plan

Disaster recovery plans detail procedures for restoring systems and data after incidents like ransomware attacks that compromise information availability.
Option a is incorrect because privacy plans protect patient confidentiality through policies, not procedures for recovering from ransomware attacks specifically.
Option b is incorrect because compliance plans ensure regulatory adherence, not specific recovery procedures after cyber security incidents affect systems.
Option d is incorrect because training plans address staff education needs, not technical procedures for system recovery after ransomware attacks.

Correct Answer: Access right

HIPAA access rights allow patients to review and obtain copies of their medical records with limited exceptions defined by law.
Option a is incorrect because accounting rights involve tracking disclosures of health information, not patient access to their own records.
Option b is incorrect because amendment rights allow corrections to records, not the basic right to review and obtain record copies.
Option d is incorrect because restriction rights limit certain uses and disclosures, not provide access to one's own medical records.

Correct Answer: Public health exception

Public health exceptions allow reporting suspected abuse to authorities without authorization to protect vulnerable individuals from harm effectively.
Option a is incorrect because treatment exceptions allow sharing for care coordination, not mandatory reporting of suspected abuse to authorities.
Option c is incorrect because payment exceptions permit billing-related disclosures, not reporting suspected abuse cases to protective service agencies specifically.
Option d is incorrect because operations exceptions cover quality improvement activities, not mandatory abuse reporting to government authorities for protection.

Correct Answer: Telehealth

Telehealth technology enables remote consultations through video connections, allowing providers in different locations to collaborate on patient care.
Option a is incorrect because patient portals provide patient access to records and communication, not provider-to-provider video consultation capabilities specifically.
Option b is incorrect because data warehouses store integrated information for analysis, not facilitate real-time video consultations between remote providers.
Option d is incorrect because health exchanges share electronic records between organizations, not enable video consultations between distant healthcare providers.

Correct Answer: CPOE

Computerized Provider Order Entry (CPOE) systems enable electronic ordering with built-in safety checks and direct pharmacy transmission capabilities.
Option a is incorrect because HIE facilitates information sharing between organizations, not specific medication ordering with interaction checking features built-in.
Option c is incorrect because PHR is maintained by patients for personal health tracking, not provider systems for electronic prescribing.
Option d is incorrect because MPI identifies patients across systems, not provides electronic prescribing with drug interaction checking capabilities specifically.

Correct Answer: Quantitative analysis

Quantitative analysis reviews records for completeness, ensuring all required documents like operative reports are present in the record.
Option a is incorrect because qualitative analysis examines documentation quality and content adequacy, not just presence of required documents specifically.
Option c is incorrect because statistical analysis evaluates numerical data patterns and trends, not medical record document completeness for compliance.
Option d is incorrect because financial analysis examines revenue and costs, not the presence of required clinical documentation in records.

Correct Answer: Serial-unit numbering

Serial-unit numbering assigns different numbers per admission while consolidating all information under the most recent number assigned systematically.
Option a is incorrect because unit numbering uses one permanent number throughout all encounters, not different numbers per admission specifically.
Option c is incorrect because terminal numbering refers to a filing method using final digits, not a patient numbering system approach.
Option d is incorrect because alphabetical numbering isn't a standard system, as alphabetical typically refers to name-based filing methods only.

Correct Answer: Shared accountability

Shared accountability distributes governance responsibility across multiple stakeholders through committee structures, ensuring comprehensive oversight of data decisions.
Option a is incorrect because individual accountability assigns responsibility to single persons, not multidisciplinary committees for governance decision-making processes.
Option c is incorrect because technical accountability focuses on IT responsibilities specifically, not broad multidisciplinary committee governance oversight structures comprehensively.
Option d is incorrect because clinical accountability addresses medical care responsibilities, not organizational data governance committee structures for decision-making.

Correct Answer: Medication reconciliation

Medication reconciliation compares medication lists across sources to identify and resolve discrepancies, ensuring accurate medication information throughout.
Option b is incorrect because medication administration involves giving drugs to patients, not comparing lists to resolve documentation discrepancies specifically.
Option c is incorrect because medication verification confirms individual drug orders, not comprehensive comparison across different documentation sources for discrepancies.
Option d is incorrect because medication authorization approves prescriptions, not the process of comparing and resolving discrepancies between systems.

Correct Answer: Brief operative note

Brief operative notes document essential surgical information immediately after procedures while awaiting completion of comprehensive operative reports later.
Option a is incorrect because discharge summaries document entire hospitalizations at discharge, not immediate post-operative findings after surgical procedures specifically.
Option c is incorrect because progress notes track daily patient status, not immediate documentation of surgical findings after operative procedures.
Option d is incorrect because consultation notes contain specialist recommendations, not immediate documentation of operative findings by the performing surgeon.