Data Content & Structure Flashcards
7 cards from real CMRT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Data Content & Structure flashcards as text
Which data element in a health record serves as the primary patient identifier across multiple visits?
Answer: Medical record number
The medical record number (MRN) is the permanent, facility-assigned identifier that links all of a patient's encounters.
Which of the following best describes a 'problem-oriented medical record' (POMR)?
Answer: Records organized around identified patient problems
The POMR, developed by Lawrence Weed, organizes documentation around a numbered problem list with SOAP notes for each problem.
What is the purpose of a 'deficiency slip' in health information management?
Answer: To track incomplete record components requiring completion
A deficiency slip identifies specific missing or incomplete items in a health record that require completion by the responsible provider.
In the context of health records, what does 'authentication' mean?
Answer: Verifying the identity of the person who created an entry
Authentication is the process of confirming the identity of the author of a health record entry, typically via signature, initials, or electronic credential.
Which standard governs the format and content of hospital discharge summaries in the United States?
Answer: The Joint Commission accreditation standards
The Joint Commission sets accreditation standards that specify required content and timelines for discharge summaries in accredited hospitals.
What is the correct term for the process of reviewing records immediately after patient discharge to ensure completeness?
Answer: Quantitative analysis
Quantitative analysis conducted post-discharge checks for the presence of all required components such as signatures, reports, and forms.
Which element is NOT typically required in an operative report?
Answer: Patient's insurance billing codes
Operative reports document clinical details of the surgery; insurance billing codes are assigned separately in the coding/billing process and are not part of the operative report itself.