Exam 8: Patient Record Requirements: Part A

When an incorrect entry is documented in the electronic health record (EHR), the responsible provider documents the correction as an addendum in a new document and a(n) _____ links the original document (that contains the incorrect entry) to the addendum.

Which is a statutory source that governs the content requirements for health records?

Which is an example of personal information associated with the health record?

Which is an example of financial information associated with the health record?

Which is an example of social information associated with the health record?

The American Health Information Management Association (AHIMA) publishes _____ concerning the content of the health record, which does not have the force of law or provide legal advice but does assist health information management professionals in maintaining accurate and complete health record.

Which permits patients to request that an amendment be made to their own health record?

The health record is defined as the _____ record generated at or by the health care provider or organization, which documents treatments and services delivered during the patient's episode of care by the provider or organization.

Health care providers and health information management professionals consider the needs of continuing patient care, education and research, defense against liability lawsuits, storage constraints, available technology, and fiscal concerns when developing _____ policies.

When creating a facility's destruction of health records policy and procedure, the HIPAA _____ rule must be addressed.

Which is a regulatory source that governs the content requirements for health records?

To ensure timeliness of entries documented in the health record, they must be made _____.

Which is an example of a clinical use of the health record?

Health data and health records are the property of the ____.

Which is an example of a nonclinical use of the health record?

Enterprise content and record management (ECRM) aids in combating potential increased costs associated with the discovery process.An example of an enterprise management principle is _____.

Which is an example of medical information associated with the health record?

Which is an institutional source that governs the content requirements for health records?

A nurse writes a verbal order from a physician on the physician order sheet in the health record; the nurse is the _____ of the entry.

The release of health records from drug and alcohol abuse programs is governed by _____ regulations.