Deck 10: Medical Records

Question 1

All the following have a specific retention period of patient records as outlined by state government laws except

A) Medi-Cal patients.
B) patient with private insurance, such as Anthem Blue Cross Insurance.
C) Know-Keene Act.
D) Workers' Compensation Cases.

Answer 1

patient with private insurance, such as Anthem Blue Cross Insurance.

Question 2

When a patient is transferred to another healthcare provider, it is important that the patient understands the following:

A) covered entity
B) Continuity of Care Record
C) standard of care
D) All of the options

Answer 2

All of the options

Question 3

How long do patient files need to be maintained before becoming inactive in a healthcare facility?

A) Six months
B) One year
C) Two years
D) Three years

Answer 3

Three years

Question 4

The acronym for all computer-generated information regarding patients is called

A) EHR.
B) PHI.
C) PIH.
D) EMR.

Question 5

In the SOAP format, the "O" would include

A) chief complaint.
B) history of present illness.
C) past family history.
D) information that the healthcare provider can measure.

Question 6

The purpose of keeping accurate medical records includes all the following except

A) serving as quality control.
B) knowing the patient's work status for insurance.
C) protecting the patient and healthcare professional in cases of negligence and malpractice.
D) allowing members of the healthcare team to communicate with one another.

Question 7

In the SOAP format, the "A" would include

A) information that the healthcare provider can measure.
B) summation of the healthcare provider's impression including the possible diagnosis.
C) past family history.
D) chief complaint.

Question 8

A law which limits the maximum time that parties have to initiate legal proceedings from the date of an alleged offense is called

A) statutes of limitations.
B) standard of care.
C) liability.
D) malpractice.

Question 9

The acronym HIPAA stands for

A) Health Insurance to Protect and Advance Act.
B) Health Insurance Portability and Accountability Act.
C) Health Insurance Privacy and Accountability Act.
D) Health Insurance Portability and Accurate Act.

Question 10

Which of the following is an appropriate guideline in making a correction on an electronic patient chart?

A) Delete the change on the patient's chart on the computer and retype the correct information.
B) Making an appropriate change by adding an addendum with the appropriate healthcare provider signing and dating the change.
C) It is not important to write a change if it is a minor omission or minor information.
D) It is not important to have approval to make changes on the patient's computer chart.

Question 11

AAA

Question 12

Clinical documentation that is electronic and is collected beyond one healthcare provider is called

A) covered entity.
B) electronic medical record.
C) electronic health record.
D) SOAP format.

Question 13

AAA

Question 14

AAA

Question 15

A patient intake form includes all the following data below except

A) insurance information.
B) consent forms for HIPAA.
C) medical history.
D) list of all medical doctors that the patient has seen.

Question 16

The acronym that represents SOAP means

A) summation of conversation, observation, assessment, plan.
B) subjective, objective, assessment, plan.
C) subjective, observation, assessment, priority.
D) None of the options

Question 17

Within the HIPAA guidelines, a patient's medical records can be shared or transferred to a covered entity, which include

A) healthcare clearinghouses.
B) academic medical centers.
C) healthcare plans.
D) All of the options

Question 18

The passage of HIPAA was enacted

A)1992.
B)1996.
C)2002.
D)2004.

Question 19

What would help in the monitoring of fraud in patient records?

A) Accurately keeping health records that only pertain to conversations with the patient
B) Inactive patient files
C) Active patient files
D) Accurate documentation with inactive and active patient files

Question 20

Which of the following meets the guideline(s) for Physical Safeguards for HIPAA?

A) Keeping work stations with PHI out of high traffic area
B) Restricting access to client data from third party using the facility equipment
C) Preventing the visibility of computer screen to unauthorized users
D) All of the options

Question 21

Records that contain medical and health information of individual patients and that maintain the HIPAA standards for privacy and security are called

A) EHR.
B) EMR.
C) HER.
D) both EMR and EHR.

Question 22

HIPAA consists of

A) three titles.
B) four titles.
C) five titles.
D) six titles.

Question 23

Based on the guidelines for HIPAA's Security Rule for Technical Safeguards, which of the following area would need to be secure to protect patient's information?

A) Data storage
B) Faxes
C) Computer systems
D) All of the options

Question 24

Which of the following imposes penalties for violations of the HIPAA Privacy Rule?

A) OIG
B) PHI
C) NPP
D) EHR

Question 25

Which of the following defines the "level of education and expertise that other healthcare providers treat the same type of chief complaint from patients"?

A) Protected health information
B) Liability
C) Covered entity
D) Standard of care

Question 26

Violators of the HIPAA Privacy Rule could face

A) criminal penalties.
B) civil penalties.
C) local penalties.
D) criminal and civil penalties.

Question 27

PHI stands for

A) patient health insurance.
B) protected health insurance.
C) protected health information.
D) private health information.

Question 28

Health plans, healthcare clearinghouses, and healthcare providers under HIPAA who electronically transmit any health information are considered

A) standard of care.
B) covered entities.
C) protected health information.
D) Continuity of Care Record.