CMRT Data Content & Structure 5 — Questions and Answers
Question 1: Which term describes the property of health data that means it is complete, consistent, and free from corruption?
- Data confidentiality
- Data integrity (Correct answer)
- Data availability
- Data portability
Correct answer: Data integrity
Data integrity ensures that health information is accurate, complete, and unaltered, which is essential for safe patient care and legal validity.
Question 2: A hospital's HIM department performs 'quantitative analysis.' What specifically does this process evaluate?
- The clinical accuracy of documented diagnoses
- Whether all required record components are present and complete (Correct answer)
- The quality of physician writing and clarity
- Whether diagnoses are supported by documented findings
Correct answer: Whether all required record components are present and complete
Quantitative analysis checks for the presence of all required documentation elements (signatures, reports, forms) without judging the clinical quality of content.
Question 3: Which of the following is an example of structured data in an EHR?
- A physician's dictated history and physical
- A scanned copy of a handwritten consent form
- A drop-down selection of 'Type 2 diabetes mellitus' (Correct answer)
- A free-text nursing narrative note
Correct answer: A drop-down selection of 'Type 2 diabetes mellitus'
Structured data consists of coded or categorized entries with predefined values (like drop-down selections) that computers can query and analyze.
Question 4: OASIS data is collected primarily for which patient population?
- Inpatient acute care patients
- Home health agency patients (Correct answer)
- Long-term care nursing home residents
- Ambulatory surgery center patients
Correct answer: Home health agency patients
The Outcome and Assessment Information Set (OASIS) is a CMS-mandated data collection tool for Medicare/Medicaid patients receiving home health services.
Question 5: A patient's record contains documentation from three different providers that disagree on the patient's allergy status. This is an example of a problem with data:
- Availability
- Confidentiality
- Consistency (Correct answer)
- Accessibility
Correct answer: Consistency
When the same data element (allergy status) has conflicting values across different sources in a record, it represents a data consistency (or integrity) problem.
Question 6: Which health record component is legally required to be obtained before any surgical procedure and documents that the patient was informed of risks and alternatives?
- Operative report
- Anesthesia record
- Informed consent (Correct answer)
- Pre-procedure assessment
Correct answer: Informed consent
Informed consent documents that the patient was provided with information about the procedure, its risks, benefits, and alternatives, and voluntarily agreed to proceed.
Question 7: In a hybrid health record environment, which challenge is most commonly associated with managing records?
- Inability to share records electronically
- Inconsistent data elements between paper and electronic portions (Correct answer)
- Lack of physician authentication options
- Excessive storage costs for paper records alone
Correct answer: Inconsistent data elements between paper and electronic portions
Hybrid records contain both paper and electronic components, creating challenges when data captured in each medium is not synchronized or consistent.
CMRT Data Content & Structure 5
Which term describes the property of health data that means it is complete, consistent, and free from corruption?