Health Records Management Flashcards
7 cards from real AHIMA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Health Records Management flashcards as text
Which federal regulation establishes the minimum necessary standard for sharing protected health information (PHI)?
Answer: HIPAA Privacy Rule
The HIPAA Privacy Rule requires that only the minimum necessary amount of PHI be used or disclosed to accomplish the intended purpose.
A patient requests amendment of their medical record because they believe a diagnosis is incorrect. Under HIPAA, the covered entity may deny the request if:
Answer: The information was not created by the covered entity
HIPAA permits denial of an amendment request if the covered entity did not create the information and the originating source is still available.
Which retention schedule should a hospital apply when state law requires records to be kept 7 years but HIPAA mandates 6 years?
Answer: Follow the state law's 7-year requirement
When state law imposes a longer retention period than HIPAA, facilities must comply with the more stringent state requirement.
What is the primary purpose of a deficiency analysis in health information management?
Answer: To track incomplete or missing documentation in medical records
Deficiency analysis identifies incomplete, missing, or unsigned documentation so that records can be completed within required timeframes.
Which document grants a specific individual the legal authority to make healthcare decisions for an incapacitated patient?
Answer: Durable power of attorney for healthcare
A durable power of attorney for healthcare designates a healthcare proxy or agent to make medical decisions when the patient cannot.
An HIM professional discovers that a physician has been signing blank medical record forms to be completed later by residents. This practice is:
Answer: A violation of medical record integrity standards
Signing blank records is fraudulent and violates medical record integrity, authentication standards, and federal anti-fraud regulations.
The legal health record (LHR) differs from the designated record set (DRS) in that the LHR:
Answer: Is defined by the organization for business and legal purposes
The LHR is defined by each organization to identify records disclosed for legal proceedings, while the DRS is a broader HIPAA concept covering records used in care or payment decisions.