Question 1

ECRM legislation controls _____.
A) All forms of data and the tools used to generate and store it
B) Just the contents of electronic tools,such as computers
C) Only business and financial records maintained on patients
D) Privacy and confidentiality of healthcare information

Accepted Answer

A

Question 2

Institutional standards of care _____.
A) Are enforceable by federal and state law
B) Can be lower than state and federal regulations
C) Do not carry the force of law
D) Have no bearing on establishing negligence

Accepted Answer

Institutional standards of care are guidelines or policies set by the institution or healthcare organization that provide information regarding the accepted and expected level of care for a specific patient population or condition. They are not enforceable by law, although failure to adhere to these standards can be used as evidence of negligence in a lawsuit. However, state and federal regulations must be followed and enforced by law. Institutional standards of care cannot be lower than state and federal regulations.

Question 3

Authorship of a health record entry may be complicated by _____.
A) Allowing the user to copy and paste,possibly into the wrong record
B) Authenticating the identification of the person making the entry
C) Taking care not to repeat entries that are no longer acceptable
D) The patient's right to alter or delete unsatisfactory entries

Accepted Answer

A

Question 4

In a negligence claim,the standard of care that considers the prevailing is the _____.
A) Federal statute/regulation
B) Hospital standard or policy
C) State statute/regulation
D) Standard that is higher

Accepted Answer

The answer of In a negligence claim,the standard of care...

Question 5

Regulations concerning medical records may control _____.
A) How they are to be maintained
B) The organization of the UB-04
C) Procedures performed by a provider
D) Ways they are photocopied

Accepted Answer

Regulations concerning medical records typically cover aspects such as how they are to be maintained, stored, accessed, and protected. The other options listed are not typically governed by medical record regulations.

Question 6

That part of the health record used for continuity of care is the _____ information.
A) Clinical
B) Demographic
C) Financial
D) Legal

Accepted Answer

Clinical information includes diagnoses, treatments, medications, and other medical information necessary for continuity of care. Demographic information is important for identification and contact purposes, financial information is mostly relevant for billing and reimbursement, and legal information pertains to consent and other legal aspects of healthcare.

Question 7

What is a process in development to combat increased costs associated with the legal discovery of the electronic health record?
A) ECRM
B) HIPAA
C) MMA
D) UNOS

Accepted Answer

ECRM (Electronic Medical Record Retrieval) is a process that allows for more efficient and cost-effective extraction of electronic health record data during legal discovery. It reduces the time and resources required for manual data extraction, resulting in reduced costs. HIPAA, MMA, and UNOS are not directly related to the legal discovery of electronic health records.

Question 8

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

Accepted Answer

The use of physician handwritten signature stamps for authenticating health record entries has been eliminated by CMS (Centers for Medicare & Medicaid Services) due to concerns over security and authenticity.

Question 9

If an item was not charted in a health record,it is presumed that _____.
A) If it wasn't documented,it wasn't done
B) It was not necessary to document that item
C) Providers can be excused for being too busy delivering care to document
D) When an order is written,it was carried out even if not documented as such

Accepted Answer

The principle in healthcare documentation is "if it wasn't documented, it wasn't done." This means that if something is not charted in a health record, it is presumed not to have happened. This principle ensures accuracy, accountability, and quality of patient care.

Question 10

The destruction of records _____.
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 maintained

Accepted Answer

Destruction of records is a necessary process that should be done in the regular course of business following a specified retention period. This is because, after a certain period, the records are no longer required, and their continued retention may take up valuable space, increase storage costs, or pose a privacy risk. However, destruction of records should always be done in compliance with applicable laws, regulations, and organizational policies to ensure that the integrity of patient care and confidentiality of information are maintained. Therefore, options A, B, and D are incorrect.

Question 11

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

Accepted Answer

The specialist authenticating their own report electronically using a password is the most secure and direct way to ensure accountability and accuracy. The other options involve individuals authenticating notes or reports that were not originally created by them, which increases the potential for errors or fraud.

Question 12

Which is a major concern regarding the destruction of records?
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.

Accepted Answer

The major concern regarding the destruction of records is maintaining the confidentiality of information that identifies patients. Healthcare facilities must ensure that sensitive information is properly destroyed to prevent any unauthorized access to patients' personal information.

Answer: C 
 Another major concern with the destruction of records is ensuring that regulatory agencies are informed about the destruction. This is important to ensure that healthcare facilities comply with all relevant laws and regulations.

Answer: D 
 It is important to ensure that third parties are not used for the destruction of sensitive information to maintain the confidentiality of the information. Healthcare facilities should have strict policies and procedures in place to ensure that confidential information is properly handled and destroyed.

Therefore, the recommended answers are A, C, and D.

Question 13

The phrase deeming authority means to substitute compliance with _____.
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 regulations

Accepted Answer

Deeming authority allows healthcare organizations to demonstrate compliance with Centers for Medicare & Medicaid Services (CMS) regulations through accreditation with approved organizations, rather than direct compliance with CMS standards.

Question 14

Which of the following are subject to strict legal requirements?
A) Abstract record
B) Electronic record
C) Paper-based record
D) Records,regardless of format

Accepted Answer

Records, regardless of format, can be subject to strict legal requirements based on their content and purpose. Some industries or organizations may have specific requirements for certain types of records, but it ultimately depends on the nature of the information being recorded and the laws and regulations that govern it.

Question 15

Regulations about medical records are enforced by _____.
A) Accreditation organizations
B) Federal and state agencies
C) Medical societies
D) Professional associations

Accepted Answer

Federal and state agencies are responsible for enforcing regulations related to medical records, such as HIPAA and HITECH. Accreditation organizations, medical societies, and professional associations may also provide guidelines and standards, but they do not have the legal authority to enforce regulations.

Question 16

Federal and state statutes (laws)that directly impact the quality of the health record include requirements about _____.
A) Documentation requirements
B) Filing claims on time
C) Justifying staffing needs
D) Transitioning to an EHR

Accepted Answer

Federal and state statutes establish documentation requirements that impact the quality of the health record. These requirements include guidelines for content, format, and accuracy, as well as regulations about when documentation should be completed and how it should be stored and archived. Filing claims on time and justifying staffing needs are not directly related to the quality of the health record, and while transitioning to an EHR may impact the quality of the health record, it is not a requirement mandated by federal or state statutes.

Question 17

When an error is made in the healthcare record,_____.
A) An addendum to the EHR or paper-based record should be documented,leaving the original entry in place
B) Eliminating the erroneous information by using correction fluid in a paper-based record is an acceptable practice
C) Make sure that the erroneous entry is deleted in its entirety,and the correct information is entered
D) The correction to the record should be made by the healthcare provider's supervisor to
Enhance reliability

Accepted Answer

It is important to maintain the integrity of the original entry while correcting the error, which can be done by adding an addendum to the existing record, explaining the error and providing the correct information. This ensures that the original entry remains as a part of the record and provides a clear trail of all changes made to the record. Eliminating erroneous information or deleting the erroneous entry in its entirety can lead to incomplete or inaccurate records. Having the healthcare provider's supervisor make the correction is not necessary as long as the healthcare provider making the correction has appropriate permissions and follows the correct protocol for making corrections.

Question 18

The legal health record is defined as that containing the _____.
A) Complete and accurate description of the patient's history,condition,and care provided
B) Electronic and legal signatures of health care providers and ancillary staff members
C) Format or method by which information documented in the health record is stored
D) Type of testing performed,including data from the chargemaster or encounter form

Accepted Answer

The legal health record is defined as the complete and accurate description of the patient's history, condition, and care provided. This includes all documentation related to the patient's care, such as progress notes, test results, and treatment plans. It is important for healthcare organizations to maintain a comprehensive and accurate legal health record to ensure patient safety, quality care, and compliance with legal and regulatory requirements.

Question 19

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

Accepted Answer

Under HIPAA, if a patient requests a correction or alteration to their health record and the provider does not agree with the need for the change, the provider can deny the request. However, they must inform the patient of the denial in writing, explaining the reason for the denial and providing information on how the patient can file a complaint or appeal the decision.

Question 20

Record retention policies address _____,
A) The length of time a record is maintained
B) When the record can be released to the patient
C) Whether a patient's record warrants storage
D) Which records can be provided pursuant to court order

Accepted Answer

Record retention policies primarily address the length of time that records should be maintained. This is to ensure that records are available for future reference or use in the event of a dispute or legal investigation. While the other options (B, C, and D) may also be important considerations for record management, they are not the primary focus of record retention policies.

Quiz 8: Patient Record Requirements

ECRM legislation controls _____.

Institutional standards of care _____.

Authorship of a health record entry may be complicated by _____.

In a negligence claim,the standard of care that considers the prevailing is the _____.

Regulations concerning medical records may control _____.

That part of the health record used for continuity of care is the _____ information.

What is a process in development to combat increased costs associated with the legal discovery of the electronic health record?

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

If an item was not charted in a health record,it is presumed that _____.

The destruction of records _____.

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

Which is a major concern regarding the destruction of records?

The phrase deeming authority means to substitute compliance with _____.

Which of the following are subject to strict legal requirements?

Regulations about medical records are enforced by _____.

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

When an error is made in the healthcare record,_____.

The legal health record is defined as that containing the _____.

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

Record retention policies address _____,