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
What is the primary purpose of the 'minimum data set' (MDS) in long-term care settings?
Answer: To assess and document resident functional status for care planning and reimbursement
The MDS is a federally mandated assessment tool used in skilled nursing facilities to evaluate resident health status and guide individualized care plans.
A physician writes 'patient denies chest pain' in a progress note. This is an example of documenting:
Answer: Subjective data
Information reported by the patient (such as denying a symptom) is subjective data, which appears in the 'S' section of a SOAP note.
Which of the following is considered a secondary purpose of the health record?
Answer: Providing data for public health surveillance
Secondary purposes of the health record include research, education, public health reporting, and legal/regulatory uses beyond direct patient care.
When correcting an error in a paper health record, the acceptable method is to:
Answer: Draw a single line through the error, date, and initial it
A single line through the error with date and initials preserves the original entry while clearly marking the correction, maintaining record integrity.
Which component of an integrated health record distinguishes it from a source-oriented record?
Answer: All reports are filed in reverse chronological order regardless of source
An integrated record intermingles documentation from all sources in strict chronological (or reverse chronological) order, unlike source-oriented records that separate by department.
What does 'genealogy' of a health record refer to in HIM practice?
Answer: Tracking the movement and custody history of a record
Record genealogy (also called chain of custody) tracks where a record has been, who has accessed it, and how it has moved or been modified over time.
Under the Uniform Hospital Discharge Data Set (UHDDS), which of the following is a required data element?
Answer: Expected payer/source of payment
Expected payer/source of payment is one of the core UHDDS data elements required for all inpatient discharges to support billing and health statistics.