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
Under UHDDS definitions, which term describes the condition that is chiefly responsible for a patient's inpatient admission?
Answer: Principal diagnosis
The principal diagnosis is the condition established after study to be chiefly responsible for causing the inpatient admission.
A 'master patient index' (MPI) primarily functions to:
Answer: Uniquely identify and locate each patient's health record
The MPI is the central database that links patient demographic identifiers to their assigned medical record numbers, enabling record retrieval.
Which type of health record format arranges documentation with the most recent entries filed first?
Answer: Reverse chronological format
Reverse chronological order places the most recent documents at the front of each section, making recent information immediately accessible.
What is a 'late entry' in health record documentation?
Answer: An entry added to document an event that occurred earlier but was not recorded at the time
A late entry documents information about a past event that was omitted from the original entry, and must be clearly labeled as such with the current date and time.
Which data set standardizes the minimum health data collected for outpatient encounters in the US?
Answer: UACDS
The Uniform Ambulatory Care Data Set (UACDS) defines the core data elements to be collected for ambulatory/outpatient care settings.
In electronic health record systems, what is a 'drop-down' or 'pick list' field designed to improve?
Answer: Data standardization and entry accuracy
Structured pick-list fields enforce standardized vocabulary, reducing data entry errors and improving consistency across records.
Which document in the health record summarizes a patient's entire hospital stay and is required to be completed within a specified timeframe after discharge?
Answer: Discharge summary
The discharge summary synthesizes the hospital course, diagnoses, procedures, condition at discharge, and follow-up plan, and must be completed per accreditation standards.