Data Content, Structure, and Information Governance
The foundation: content, structure, and stewardship
This domain tests whether you understand what health data is, how it is organized, and who controls it. Start with data content standards: vocabularies and terminologies such as ICD-10-CM/PCS, SNOMED CT, LOINC, RxNorm, and CPT each serve a distinct purpose, and exam items frequently swap them to see if you notice. LOINC labels observations, SNOMED CT supports clinical granularity and interoperability, and ICD-10-CM classifies diagnoses for reporting and reimbursement. Content also includes the legal health record, its designated record set, and the distinction between the record of care and secondary data.
Structure covers the data model: the EHR versus the paper chart, the master patient index, data dictionaries, data sets (for example, the uniform hospital discharge data set), and the concept of data architecture and interoperability standards such as HL7 FHIR. Know the difference between a data dictionary (defines elements and permissible values) and a data model (relationships among elements).
Governance is the accountability framework: data ownership, stewardship, stewardship councils, data quality dimensions (accuracy, completeness, consistency, timeliness, validity, uniqueness), information lifecycle management from creation through destruction, retention schedules, and legal hold. Privacy and security controls sit inside governance but are tested separately under health law.
Trap: Questions conflate data governance (policy and accountability) with data management (execution). Another frequent trap is treating the complete medical record as identical to the designated record set, which is a subset defined by patient access rules.
Rule of thumb: Ask "who decides?" for governance, "what is stored where and in what format?" for structure, and "what does this element mean and what values are allowed?" for content.