Deck 8: Patient Record Requirements: Part A

Question 1

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

A)American Osteopathic Association standards
B)Medical staff bylaws, rules and regulations
C)Medicare Conditions of Participation
D)State codes, rules and regulations

Answer 1

Medicare Conditions of Participation

Question 2

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

A)American Osteopathic Association standards
B)Medical staff bylaws, rules and regulations
C)Medicare Conditions of Participation
D)State codes, rules and regulations

Answer 2

Medical staff bylaws, rules and regulations

Question 3

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

A)at the convenience of the provider, whenever s/he is at the facility
B)during the actual occurrence of the event or very shortly thereafter
C)the next time the provider can be on site at the health care facility
D)when the health record is available for the provider to do so

Answer 3

during the actual occurrence of the event or very shortly thereafter

Question 4

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

A)Billing and reimbursement
B)Chronological documentation of care
C)Serves as medicolegal document
D)Verification of medical disability

Question 5

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

A)Alcohol, tobacco, and work history
B)Demographic data, such as address
C)Test results and operations reports
D)Third-party payer information

Question 6

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.

A)business
B)legal
C)medical
D)valid

Question 7

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

A)Health Insurance Portability & Accountability Act
B)Joint Commission accreditation standards
C)Medical staff bylaws, rules and regulations
D)State codes, rules and regulations

Question 8

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 _____.

A)creating both digital and analog records for use in the facility
B)differentiating between clinical and nonclinical health record content
C)policies established about how long to save emails and text files
D)streamlining the process of responding to discovery requests

Question 9

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

A)Alcohol, tobacco, and work history
B)Demographic data, such as address
C)Test results and operative reports
D)Third-party payer information

Question 10

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

A)Billing to and reimbursement by third-party payers
B)Chronological documentation of patient care
C)Public health monitoring to determine flu outbreaks
D)Quality improvement activities, such as infection control

Question 11

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.

A)authenticator
B)author
C)editor
D)transcriber

Question 12

Which is a possible consequence of the if it wasn't documented, it wasn't done concept?

A)Deficiencies found in the health record are corrected by responsible providers.
B)Patients are notified by the risk manager that they are eligible bring a lawsuit.
C)The responsible provider is automatically suspended from the medical staff.
D)Third-party payer review of the health record can result in payment denials.

Question 13

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

A)ARRA
B)CMS CoP
C)EMTALA
D)HIPAA

Question 14

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

A)American Osteopathic Association standards
B)Medical staff bylaws, rules and regulations
C)Medicare Conditions of Participation
D)State codes, rules and regulations

Question 15

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

A)Alcohol, tobacco, and work history
B)Demographic data, such as address
C)Test results and operations reports
D)Third-party payer information

Question 16

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.

A)Accreditation standards
B)Medical bylaws and rules
C)Practice briefs
D)Statutory rules

Question 17

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.

A)chart completion and deficiency analysis
B)enterprise content and record management
C)quality management and utilization review
D)record retention and record destruction

Question 18

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.

A)computer code
B)e-signature
C)nursing entry
D)physician order

Question 19

When an incorrect entry is documented in the paper-based health record, the responsible provider can _____.

A)cross out the entire incorrect entry using a single line, documenting the correct entry immediately below the incorrect entry and dating the entry
B)delete the entire entry by removing the report on which the incorrect entry was made, documenting corrected entries on a new page in the record
C)draw a single line through the incorrect entry; write the word "error" next to it; date, time and initialize the incorrect entry; and enter the reason for correction
D)obliterate entire incorrect entry (e.g., using a black magic marker), and document the correct entry in the next available space in the patient record

Question 20

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

A)Alcohol, tobacco, and work history
B)Demographic data, such as address
C)Test results and operative reports
D)Third-party payer information

Question 21

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

A)accountability
B)portability
C)privacy
D)security

Question 22

When a health care facility files for bankruptcy and closes, a _____ is appointed to make decisions for the bankrupt health care provider.

A)case trustee
B)federal agency
C)licensing authority
D)third-party payer

Question 23

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

A)county
B)federal
C)municipal
D)state

Question 24

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

A)centers for medicare and medicaid
B)owner of the health care facility
C)patient (or patient's next of kin)
D)state in which the facility operates