QUESTION: 1

In preparation for an HER, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is

recovery room record.
pathology report.
operative report.
discharge summary.

Answer(s): B

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QUESTION: 2

Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS, but not in the UHDDS would be

personal identification.
cognitive patterns.
procedures and dates.
principal diagnosis.

Answer(s): B

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QUESTION: 3

A good first step toward protecting the security of data contained in a health information computer system would be to

establish a good record tracking system.
define levels of security for different types of information, depending on sensitivity.
provide remote terminals for improved access to the record.
provide internet access to facility records.

Answer(s): B

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