CMRT Data Content & Structure 2

Question 1

Which data element in a health record serves as the primary patient identifier across multiple visits?

Accepted Answer

Medical record number

Answer

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)?

Accepted Answer

Records organized around identified patient problems

Answer

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?

Accepted Answer

To track incomplete record components requiring completion

Answer

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?

Accepted Answer

Verifying the identity of the person who created an entry

Answer

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?

Accepted Answer

The Joint Commission accreditation standards

Answer

The Joint Commission sets accreditation standards that specify required content and timelines for discharge summaries in accredited hospitals.

(CMRT) Certified Medical Records Technician Practice Test

(CMRT) Certified Medical Records Technician Practice Test

CMRT Data Content & Structure 2