CMRT Data Content & Structure 3

Question 1

Under UHDDS definitions, which term describes the condition that is chiefly responsible for a patient's inpatient admission?

Accepted Answer

Principal diagnosis

Answer

The principal diagnosis is the condition established after study to be chiefly responsible for causing the inpatient admission.

Question 2

A 'master patient index' (MPI) primarily functions to:

Accepted Answer

Uniquely identify and locate each patient's health record

Answer

The MPI is the central database that links patient demographic identifiers to their assigned medical record numbers, enabling record retrieval.

Question 3

Which type of health record format arranges documentation with the most recent entries filed first?

Accepted Answer

Reverse chronological format

Answer

Reverse chronological order places the most recent documents at the front of each section, making recent information immediately accessible.

Question 4

What is a 'late entry' in health record documentation?

Accepted Answer

An entry added to document an event that occurred earlier but was not recorded at the time

Answer

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.

Question 5

Which data set standardizes the minimum health data collected for outpatient encounters in the US?

Accepted Answer

UACDS

Answer

The Uniform Ambulatory Care Data Set (UACDS) defines the core data elements to be collected for ambulatory/outpatient care settings.

(CMRT) Certified Medical Records Technician Practice Test

(CMRT) Certified Medical Records Technician Practice Test

CMRT Data Content & Structure 3