CMRT Data Content & Structure 3 — Questions and Answers
Question 1: Under UHDDS definitions, which term describes the condition that is chiefly responsible for a patient's inpatient admission?
- Present on admission condition
- Principal diagnosis (Correct answer)
- Primary problem
- Admitting complaint
Correct answer: Principal diagnosis
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:
- Store scanned images of paper records
- Uniquely identify and locate each patient's health record (Correct answer)
- Assign ICD-10 codes to diagnoses
- Generate physician credentialing reports
Correct answer: Uniquely identify and locate each patient's health record
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?
- Problem-oriented format
- Integrated format
- Reverse chronological format (Correct answer)
- Source-oriented format
Correct answer: Reverse chronological format
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?
- A note added after the record has been coded and billed
- An entry added to document an event that occurred earlier but was not recorded at the time (Correct answer)
- Any note written more than 24 hours after patient discharge
- A correction made to an existing entry
Correct answer: An entry added to document an event that occurred earlier but was not recorded at the time
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?
- UHDDS
- UACDS (Correct answer)
- MDS
- OASIS
Correct answer: UACDS
The Uniform Ambulatory Care Data Set (UACDS) defines the core data elements to be collected for ambulatory/outpatient care settings.
Question 6: In electronic health record systems, what is a 'drop-down' or 'pick list' field designed to improve?
- Free-text narrative detail
- Data standardization and entry accuracy (Correct answer)
- Record encryption strength
- Chart release speed
Correct answer: Data standardization and entry accuracy
Structured pick-list fields enforce standardized vocabulary, reducing data entry errors and improving consistency across records.
Question 7: Which document in the health record summarizes a patient's entire hospital stay and is required to be completed within a specified timeframe after discharge?
- History and physical
- Nursing admission assessment
- Discharge summary (Correct answer)
- Consultation report
Correct answer: Discharge summary
The discharge summary synthesizes the hospital course, diagnoses, procedures, condition at discharge, and follow-up plan, and must be completed per accreditation standards.
CMRT Data Content & Structure 3
Under UHDDS definitions, which term describes the condition that is chiefly responsible for a patient's inpatient admission?