CMRT Data Content & Structure 2 — Questions and Answers
Question 1: Which data element in a health record serves as the primary patient identifier across multiple visits?
- Medical record number (Correct answer)
- Account number
- Social Security number
- Date of birth
Correct answer: Medical record number
The medical record number (MRN) is the permanent, facility-assigned identifier that links all of a patient's encounters.
Question 2: Which of the following best describes a 'problem-oriented medical record' (POMR)?
- Records organized by care provider
- Records organized around identified patient problems (Correct answer)
- Records organized chronologically by date
- Records organized by department
Correct 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.
Question 3: What is the purpose of a 'deficiency slip' in health information management?
- To document billing errors
- To track incomplete record components requiring completion (Correct answer)
- To flag duplicate medical record numbers
- To identify coding inaccuracies
Correct 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.
Question 4: In the context of health records, what does 'authentication' mean?
- Encrypting the record for secure transmission
- Verifying the identity of the person who created an entry (Correct answer)
- Converting paper records to electronic format
- Assigning a diagnosis code to a record
Correct 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.
Question 5: Which standard governs the format and content of hospital discharge summaries in the United States?
- HIPAA Privacy Rule
- The Joint Commission accreditation standards (Correct answer)
- ICD-10-CM Official Guidelines
- UHDDS data set requirements
Correct answer: The Joint Commission accreditation standards
The Joint Commission sets accreditation standards that specify required content and timelines for discharge summaries in accredited hospitals.
Question 6: What is the correct term for the process of reviewing records immediately after patient discharge to ensure completeness?
- Concurrent review
- Retrospective review
- Quantitative analysis (Correct answer)
- Prospective review
Correct answer: Quantitative analysis
Quantitative analysis conducted post-discharge checks for the presence of all required components such as signatures, reports, and forms.
Question 7: Which element is NOT typically required in an operative report?
- Name of surgeon and assistants
- Findings during the procedure
- Patient's insurance billing codes (Correct answer)
- Description of technique used
Correct 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.
CMRT Data Content & Structure 2
Which data element in a health record serves as the primary patient identifier across multiple visits?