CMRT Data Content & Structure 4 — Questions and Answers
Question 1: What is the primary purpose of the 'minimum data set' (MDS) in long-term care settings?
- To assign ICD-10 codes for nursing home residents
- To assess and document resident functional status for care planning and reimbursement (Correct answer)
- To track hospital readmission rates
- To audit medication administration records
Correct answer: To assess and document resident functional status for care planning and reimbursement
The MDS is a federally mandated assessment tool used in skilled nursing facilities to evaluate resident health status and guide individualized care plans.
Question 2: A physician writes 'patient denies chest pain' in a progress note. This is an example of documenting:
- Objective data
- Assessment data
- Subjective data (Correct answer)
- Plan data
Correct answer: Subjective data
Information reported by the patient (such as denying a symptom) is subjective data, which appears in the 'S' section of a SOAP note.
Question 3: Which of the following is considered a secondary purpose of the health record?
- Documenting patient care decisions
- Supporting clinical communication between providers
- Providing data for public health surveillance (Correct answer)
- Recording medication administration
Correct answer: Providing data for public health surveillance
Secondary purposes of the health record include research, education, public health reporting, and legal/regulatory uses beyond direct patient care.
Question 4: When correcting an error in a paper health record, the acceptable method is to:
- Use correction fluid (white-out) to cover the error
- Draw a single line through the error, date, and initial it (Correct answer)
- Erase the error completely
- Tear out the page and rewrite the entry
Correct answer: Draw a single line through the error, date, and initial it
A single line through the error with date and initials preserves the original entry while clearly marking the correction, maintaining record integrity.
Question 5: Which component of an integrated health record distinguishes it from a source-oriented record?
- All reports are filed in reverse chronological order regardless of source (Correct answer)
- Documents are grouped by type (labs, radiology, nursing)
- The problem list drives all documentation
- Physician notes are filed separately from nursing notes
Correct answer: All reports are filed in reverse chronological order regardless of source
An integrated record intermingles documentation from all sources in strict chronological (or reverse chronological) order, unlike source-oriented records that separate by department.
Question 6: What does 'genealogy' of a health record refer to in HIM practice?
- Tracing the patient's family medical history
- Tracking the movement and custody history of a record (Correct answer)
- The patient's ancestry recorded in demographics
- The version history of an electronic document
Correct answer: Tracking the movement and custody history of a record
Record genealogy (also called chain of custody) tracks where a record has been, who has accessed it, and how it has moved or been modified over time.
Question 7: Under the Uniform Hospital Discharge Data Set (UHDDS), which of the following is a required data element?
- Patient's employment status
- Expected payer/source of payment (Correct answer)
- Patient's religious affiliation
- Patient's marital history
Correct answer: Expected payer/source of payment
Expected payer/source of payment is one of the core UHDDS data elements required for all inpatient discharges to support billing and health statistics.
CMRT Data Content & Structure 4
What is the primary purpose of the 'minimum data set' (MDS) in long-term care settings?