Data Content, Structure, and Information Governance
Content and structure
Health information professionals must know the data elements that make up a health record, the standardized data sets used in each care setting, and how records are organized. UHDDS is the inpatient acute-care data set; MDS applies to long-term care, OASIS to home health, and DEEDS to emergency department care. Distinguish the legal health record (what the organization designates as its official record) from the designated record set (a broader HIPAA term covering records used to make decisions about the patient). Primary data come from the patient encounter; secondary data are derived for other uses such as registries, indices, and data warehouses.
Data quality
Know the ten data-quality characteristics: accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy, and timeliness. Questions often swap definitions, for example confusing granularity (level of detail) with precision (exactness).
Governance and lifecycle
Data governance assigns decision rights and accountability for data assets; data stewardship is the operational responsibility. The master patient index (MPI) is the key patient-identity file, and duplicate rate is a governance metric. Retention schedules must satisfy federal, state, and payer rules, with legal holds overriding destruction.
Rule of thumb
When a question asks whether something belongs in the legal health record, ask whether the organization designated it as the official record of care. If the question asks about patient access under HIPAA, think designated record set.