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 term describes the property of health data that means it is complete, consistent, and free from corruption?
Answer: Data integrity
Data integrity ensures that health information is accurate, complete, and unaltered, which is essential for safe patient care and legal validity.
A hospital's HIM department performs 'quantitative analysis.' What specifically does this process evaluate?
Answer: Whether all required record components are present and complete
Quantitative analysis checks for the presence of all required documentation elements (signatures, reports, forms) without judging the clinical quality of content.
Which of the following is an example of structured data in an EHR?
Answer: A drop-down selection of 'Type 2 diabetes mellitus'
Structured data consists of coded or categorized entries with predefined values (like drop-down selections) that computers can query and analyze.
OASIS data is collected primarily for which patient population?
Answer: Home health agency patients
The Outcome and Assessment Information Set (OASIS) is a CMS-mandated data collection tool for Medicare/Medicaid patients receiving home health services.
A patient's record contains documentation from three different providers that disagree on the patient's allergy status. This is an example of a problem with data:
Answer: Consistency
When the same data element (allergy status) has conflicting values across different sources in a record, it represents a data consistency (or integrity) problem.
Which health record component is legally required to be obtained before any surgical procedure and documents that the patient was informed of risks and alternatives?
Answer: Informed consent
Informed consent documents that the patient was provided with information about the procedure, its risks, benefits, and alternatives, and voluntarily agreed to proceed.
In a hybrid health record environment, which challenge is most commonly associated with managing records?
Answer: Inconsistent data elements between paper and electronic portions
Hybrid records contain both paper and electronic components, creating challenges when data captured in each medium is not synchronized or consistent.