Question 1

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.

Accepted Answer

A)   Computer code
B)   E-signature
C)   Nursing entry
D)   Physician orderE) All of the above
F) A) and D)

Question 2

Which of the following are subject to strict legal requirements?

Accepted Answer

A)   Abstract record
B)   Electronic record
C)   Paper-based record
D)   Records, regardless of formatE) None of the above
F) B) and D)

Question 3

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

Accepted Answer

A)   Case trustee
B)   Federal agency
C)   Licensing authority
D)   Third-party payerE) B) and D)
F) A) and C)

Question 4

The use of physician handwritten signature stamps to authenticate health record entries _____.

Accepted Answer

A)   Has been eliminated by CMS
B)   Is considered acceptable by CMS
C)   Proves to be a best practice standard
D)   Saves time for physicians and their designeesE) A) and B)
F) A) and C)

Question 5

The phrase deeming authority means to substitute compliance with _____.

Accepted Answer

A)   Accreditation standards for compliance with CMS regulations
B)   CMS regulations for compliance with state standards
C)   Federal or state statutes (laws)  with accreditation standards
D)   Quality review organization requirements with federal regulationsE) None of the above
F) A) and C)

Question 6

Regulations concerning medical records may control _____.

Accepted Answer

A)   How they are to be maintained
B)   The organization of the UB-04
C)   Procedures performed by a provider
D)   Ways they are photocopiedE) A) and B)
F) B) and C)

Question 7

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

Accepted Answer

A)   Alcohol, tobacco, and work history
B)   Demographic data, such as address
C)   Test results and operative reports
D)   Third-party payer informationE) C) and D)
F) All of the above

Question 8

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

Accepted Answer

A)   County
B)   Federal
C)   Municipal
D)   StateE) All of the above
F) C) and D)

Question 9

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 _____.

Accepted Answer

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

Question 10

Which is a major concern regarding the destruction of records?

Accepted Answer

A)   Information that identifies patients must be maintained as confidential.
B)   Prohibitive costs impact the quality of care provided to patients.
C)   Regulatory agencies might not have been informed about the destruction.
D)   Third parties must never be used for destruction of sensitive information.E) None of the above
F) B) and C)

Question 11

Federal and state statutes (laws)  that directly impact the quality of the health record include requirements about _____.

Accepted Answer

A)   Documentation requirements
B)   Filing claims on time
C)   Justifying staffing needs
D)   Transitioning to an EHRE) None of the above
F) A) and B)

Question 12

J.C. and AOA are accrediting bodies.

Accepted Answer

A) True 
 B)False

Question 13

After the destruction of records, a certificate of destruction ____.

Accepted Answer

A)   Applies only if the destruction of records was performed by a third party
B)   Indicates what was destroyed as well as the method of destruction
C)   May implicate the healthcare organization and providers in a legal action
D)   Often proves unnecessary because the health records no longer existE) B) and C)
F) A) and B)

Question 14

If a patient requests that his health record be corrected or altered, the provider may accomplish this by _____.

Accepted Answer

A)   Deleting the original information and documenting the corrected information
B)   Denying the patient's request by informing the patient of this in writing
C)   Refusing to make corrections/alterations because patients don't have this right
D)   Requiring that a local judge review the patient's request to correct or alter dataE) A) and B)
F) B) and C)

Question 15

The destruction of records _____.

Accepted Answer

A)   Can be done when requests for the production of documents legally endangers an organization
B)   Is performed at the discretion of the health information manager due to storage concerns
C)   May be performed in the regular course of business following a specified retention period
D)   Should never be performed so that the integrity of patient care is consistently maintainedE) B) and C)
F) A) and D)

Question 16

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

Accepted Answer

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.E) A) and D)
F) B) and C)

Question 17

Which is an example of acceptable authentication of a medical record entry?

Accepted Answer

A)   Nurse who authenticates notes documented by another nurse who went off shift.
B)   Nurse practitioner who authenticates notes documented by the physician.
C)   Physician who authenticates reports dictated by colleagues within his practice.
D)   Specialist who authenticates his own dictated report electronically using a password.E) C) and D)
F) B) and C)

Question 18

Regulations about medical records are enforced by _____.

Accepted Answer

A)   Accreditation organizations
B)   Federal and state agencies
C)   Medical societies
D)   Professional associationsE) A) and B)
F) A) and D)

Question 19

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

Accepted Answer

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

Exam 8: Patient Record Requirements

The destruction of records _____.

Correct Answer
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Regulations concerning medical records may control _____.

Correct Answer
verified

Which is a major concern regarding the destruction of records?

Correct Answer
verified

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 _____.

Correct Answer
verified

J.C. and AOA are accrediting bodies.

Correct Answer
verified

After the destruction of records, a certificate of destruction ____.

Correct Answer
verified

Federal and state statutes (laws) that directly impact the quality of the health record include requirements about _____.

Correct Answer
verified

If a patient requests that his health record be corrected or altered, the provider may accomplish this by _____.

Correct Answer
verified

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

Correct Answer
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Which is an example of acceptable authentication of a medical record entry?

Correct Answer
verified

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

Correct Answer
verified

Regulations about medical records are enforced by _____.

Correct Answer
verified

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

Correct Answer
verified

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

Correct Answer
verified

The use of physician handwritten signature stamps to authenticate health record entries _____.

Correct Answer
verified

The phrase deeming authority means to substitute compliance with _____.

Correct Answer
verified

Which of the following are subject to strict legal requirements?

Correct Answer
verified

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.

Correct Answer
verified

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

Correct Answer
verified

Exam 8: Patient Record Requirements

The destruction of records _____.

Correct AnswerverifiedShow Answer

Regulations concerning medical records may control _____.

Correct AnswerverifiedShow Answer

Which is a major concern regarding the destruction of records?

Correct AnswerverifiedShow Answer

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 _____.

Correct AnswerverifiedShow Answer

J.C. and AOA are accrediting bodies.

Correct AnswerverifiedShow Answer

After the destruction of records, a certificate of destruction ____.

Correct AnswerverifiedShow Answer

Federal and state statutes (laws) that directly impact the quality of the health record include requirements about _____.

Correct AnswerverifiedShow Answer

If a patient requests that his health record be corrected or altered, the provider may accomplish this by _____.

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

Which is an example of acceptable authentication of a medical record entry?

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

Regulations about medical records are enforced by _____.

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

The use of physician handwritten signature stamps to authenticate health record entries _____.

Correct AnswerverifiedShow Answer

The phrase deeming authority means to substitute compliance with _____.

Correct AnswerverifiedShow Answer

Which of the following are subject to strict legal requirements?

Correct AnswerverifiedShow Answer

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.

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

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